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MEDICAL SCIENCE

Abstracts & Reviews

V^OLUiME IV

APRIL— SEPTEx\[BER 1931

Published for

THE MEDICAL RESEARCH COUNCIL

HUMPHREY MILFOKD

OXFORD UNIVERSITY PRESS

LONDON EDINBURGH GLASGOW COPENHAGEN

NEW YORK TORONTO MELBOURNE CAPE TOWN

BOMBAY CALCUTTA MADRAS SHANGHAI

CONTRIBUTORS TO VOLUME IV

[Key to initials given at end of each revieto and abstract)

A E A. E. Quine, F.E.C.S.

C d F " C. da Fano, M.D., L.D., F.R.M.S.

Q Y M C. F. Marshall, F.R.C.S.

C* G l' W. C. G. L. Wolf, M.D.

Q L C. Lillingston, M.D.

Q l' E. C- Lovatt Evans, D.Sc, M.R.C.S., L.R.C.P.

y T) A E. J). Adrian, M.D.

E* M W Eva Muriel White, M.R.C.S.. L.R.C.P., D.M.R.E.

F M R W F. M. R. Walshe, M.D., F.R.C.P.

Q j' ' G. Jefferson, M.S., F.R.C.S.

g" T W. G- T. Western, M.D.

Q ^^ ' Gordon Ward, M.D.

H d' Haldin Davis, F.R.C.S., M.R.C.P

h" e' R H. E. Roaf, M.D., D.Sc.

h' W D H. W. Dudley, O.B.E., M.Sc, Ph.D.

h! W. H. H. W. Hills, M.D., M.R.C.P., D.P.M.. B.Sc.

J *p R ' J. D. Rolleston, M.D.

J* R* p'. J. R. Perdrau, M.B., B.S., M.R.C.S., L.R.C.P.

L H C L. H. Clark, B.Sc.

N H M B Noel H. M. Burke, M.R.C.S., L.R.C.P.

L V de W O. L. V. de Wesselow, M.B., B.Ch., M.R.C.P.

P* F.' P. Fildes, O.B.E., M.B., B.C.

p L -B P- Lazarus-Barlow, M.B., B.Ch.

R* A p R- A. Peters, M.C., M.B., B.C.

K S."W. R. S. Woods, M.D., M.R.C.P.

S. R. Sidney Russ, D.Sc.

S U L.-B. Sybil U. Lazarus-Barlow.

T. A. R. T. A. Ross, M.D., F.R.C.P.

T W P L T. W. P. Lawrence, F.R.C.S.

W A M S W. A. M. Smart, M.R.C.S., L.R.C.P., B.Sc.

W B W. Bulloch, M.D., LL.D., F.R.S.

W' C ' W. Cramer, Ph.D., D.Sc, M.R.C.S., L.R.C.P.

w! G. S. W. G. Spencer, O.B.E., M.S., F.R.C.S.

W. M. B. W. M. Bayliss, D.Sc, F.R.S.

W. S. L.-B. ' W. S. Lazarus-Barlow, M.D., F.R.C.P.

W. T. W. Trotter, M.S., F.R.C.S.

W. W. W. W. W. W oods, M.R^ .S., L.R.C.P.

-,UG2 3 1986

10 1 7. i i

I. INDEX OF SUBJECTS

Biochemistry, 8 J, 173, 273, 376, 4fi8, 573,
Neurology, 53, )46, 242, 347, 441, 547.
Pathology and bacteriology, 57, 152, 256,

352, 450, 550.
Radiology and electrology, 91, 181, 283,

388, 481, 581.
Surgery, 52, 239, 341,435.
Acacia-glucose solutions, influence of intra-
venous injections of, on urine secretion
and blood-volume in rabbits, 277.
Acanthosis nigricans with carcinoma of in-
ternal organs, 114.
Acetaldehyde, identification of aldehyde-like
substance in diabetic urine as, 576.
as intermediary substance in fermentation

of sugar by B. ladis aerogvnes, 388.
formation of, during decomposition of sugar
by moulds, 388.
Aceto-nitrite reaction, 578.
Acidosi^in toxaemias of pregnancy, 537.
Acriflavine, antiseptic potency of, 465.
Acromegaly, radiotherapy of, 582.
Actinomycetes, acid-fast, with report of case
from which a new species was isolated,
261.
Actinotherapy of three cases of tumour of

hypophj'sis, 486.
Addison's disease, cause of skin colour in,

231.
Adrenalin, effects of, on respiratory exchange,
274.
glycaemia, 576.

test for pancreatic insufficiency, 514.
in treatment of erythromelalgia, 112.
Adrenals, post-operative depletion of epine-

phrin store of, 476.
Agglutinating sera, action of continuous

electric current on, 355.
Agglutination, isoelectric point of red blood
cells and its relation to, 176.
and sedimentation of bacteria, 176.
Albuminous substances and saline solutions,

' intertraction ' between, 577.
Alcohol, ethyl, influence of, on organism, 463.
Alimentary diseases, 3.

Alkali reserve of blood, relation of, to glyco-
suria and hyperglycaemia in pancreatic
diabetes, 173.
Alopecia areata an abortive form of general

syphilis, 113.
Amino-acids, oxidation of, by blood charcoal,

480.
' Ammonia coefficient ' of pregnancy, 89.
lY.

Amoeba, parasitic, new species of, •ccurring
in crypts of tonsils {Entamoeba macro-
lixjalina), 457.
Amoebic abscess (^f liver, treatment of, 403.
Anaemia, acute experimental, blood phos-
phates in lipaemia produced by, 174.
acute, lipaemia in, 88.
severe, carbon dioxide absorption curve and

carbon dioxide tension in, 381.
splenic, 119.
Anaerobic flora of intestine in some morbid
states, 159.
germs, cultures of, in ordinary Petri dishes
in presence of air, 354.
Anaerobiosis, chemical criteria of, with
special reference to methylene blue, 453.
factors influencing. 454.
Anaesthesia, spinal, regional, and local, 516.
Analgesia, general, by cocaine injected into

spinal theca, 522.
Anaphylactic bronchial asthma, 310.
food reactions and eczema, 110.
shock, influence of spleen, kidney, and

thyroid on, 169.
— , simple and harmless method of pre-
venting, 458.
Anaphylaxis, blood picture in, 358.

ocular reactions in, 164.
Aneurysm, arteriovenous, between carotid
artery and cavernous sinus, 424.
of carotid and vertebral arteries, 322.
Angina pectoris in diabetic patients, 499.
Angioma, gastric, 10.

Ankylostomiasis in coloured prisoners of war
in Germany, 105.
in Costa Rica, effects of treatment on, 106.
in India, 106.

in natives of Zaragoza, 107.
in N. Queensland, 106.
treatment of, 106, 107.
Annular ligament, incision of, in treatment

of acute suppuration of wrist, 236.
Anoxaemia and cerebral activity, 430.

eff'ects of, on spinal reflex mechanism, 428.
lactic acid in blood in, 376.
in production of symptoms in disease and
injury of nervous system, 427.
Anthelmintics, chemical composition and

therapeutic value of, 106.
Anthrax, haemorrhagic meningo-encephalitis
in, 161.
infection in rats, experiments on, 161.
Antibodv formation, effect of mustard gas on,
369."

I. INDEX OF SUBJECTS

Antiseptics, variability in results of testing,

465.
Anxiety hysteria, 3411.

'Aolan' and turpentine, intramuscular injec-
tions of, in treatment of gonorrhoea, 214.
Aortitis, congenital syphilitic, 410.

syphilitic, gastro-intestinal haemorrhage
in, 11.
Appendix vcrmiforniis, haeniolytic strepto-
cocci of, 257.
oxyuriasis of, 105.
Arsenic poisoning, magnesium sulphate in,

282.
Arsenical compounds in treatment of gono-
rrhoea! salpingitis, 216.
Arsphenamine, some factors relating to toxic

action of, 580.
Arteries, injury causing spasmodic contrac-
tion of, 33.
Arthritis, chi'onic, bacteriologic studies in,
70.
dysenteric, 400.

gonorrhoeal, complicated by keratodermia
blennorrhagica, 212.
Ascariasis, tongue sign in, 108.
Ascarides, intestinal obstruction caused by,
104.
invasion of pancreas by, 104.
— of lungs by, 104.
Aacaris lumbricoides causing haemolytic jaun-
dice, 105.
distribution and effects of. 104.
Ascites, chylous, due to carcinoma of stomach,
8.
in connexion with duodenal ulcer, 5.
Aspergillosis, pulmonary, 317.
Aspergillus fumigafus, infection with, com-
plicating influenza, 298.
Asphyxia, action of, on spinal animal, 429.
Asthma, bronchial, 310.
— , treatment of, 312.
vagotonia in, 312.
Asthmatics, anaphylactic deaths in, 311.
Auto-haemagglutination, 358.
Autolysin, bacterial, transmissible, 62.
Autolysis, effect of certain colloids upon, 86.

, microbic, transmissible, 74.
Auto-oxidizable constituent of the cell, 573.
Auto-suggestion, 244.

Badlli's acirhphilus, intestinal implantation

of, 90, 178.
anikracis, action in vitro of neosalvarsan on,

458.
bofuJini's, heat resistance of spores of, 352.
Bacillus carrier state, mechanism of, with

special reference to Friedlaender bacillus,

467.
Bacillus coli, amount of heat liberated by,

when grown in presence of free amino-

acids, 567.

— in intestine of small herbivora, 76.
influenzae, accidental inoculation of, on

mucous membranes of healthy persons
with development of infection in at
least one, 267.

— antigens, complement fixation in in-
fluenza with, 155.

Bacillus influemof., behaviour of, in mixed
culture on haemoglobin-free media, 156.

— , biology of, 58.

— , grouping of, with special reference to
permanence of type in carrier, 267.

■ — , growth of, in haemoglobin-free media,
562.

— isolated from meningitis, 561.

— , nature of effect of blood-pigment upon
growth of, 156.

— pneumonia in monkeys, 153.

— , production in monkeys of disease re-
sembling influenza by inoculation with,
153.

— , relation of different strains of, as shown
by cross-agglutination and absorption
tests, 155.

— , serology of, 267.

— , virulent, acute respiratory infection in
man following inoculation with, 264.

leprae, cultivation of, 558.

proteus, biology and biochemistry of, 80.

— , comparative studies on races of, with
special reference to their capability to
produce haeniotoxin, 272.

— , sub-groups of. Cross-agglutination as
a differential diagnostic means, 272.

— of war wounds, 451.

pyocyaneus, bactericidal action of radium
on, 187.
Bacillus of rabbit septicaemia, coexistence of
individuals of different degrees of viru-
lence in cultures of, 568.
Bacillus spermoides, a new anaerobic soil
bacillus, 160.
typhosus, viability and growth of, in bile, 79.
welchii infections in dogs suffering from
experimental diabetes, 273.
Bacilli, acid-resisting, changes shown by, on

passing through animal organism, 452.
Bacteria, agglutination and sedimentation of,
176.
communal activity of, 91.
urowth accessory substances in nutrition

of, 387.
in vivo as in vitro, pass through walls of

filters, 255.
simple procedure for accurate enumeration
of, without use of counting chamber, 364.
Bacterial nutrition, studies on, 562.
Bactericidal action of secondary rays from

colloidal metals, 94.
Bacteriology (^abstracts), 57, 152, 255, 352,

450, 550.
Bacteriophage, d'HerelleV, production and
interpretation of, 62.
presence of, in healthy intestine, in soil
and in water, 74.
Bacteriophagic microbe, 74.
principle of d'Herelle, 74.
Bacterium pneumositites, 5&1.
Basal ganglia, mental disturbances in tumoui-s

of, 447.
Behriiig's toxin-antitoxin mixture, practical
protective value of, against diphtheria,
454.
Benzidin peroxidase reaction, variations in,
depending on fixative, physiological
activity, and type of animal, 68.

I. INDEX OF SUBJECTS

Benzyl benzoate in treatment of dvsenteiy,
404.

— in treatment of whooping cough, 203.
Bile-duct, surgical union of, with duodenum,
jejunum, or stomach, 131.

cancer of, 129.

kinkiniiof, 128.
Bile-ducts, congenital obliteration of, 127.
Bile eneinata in treatment of lonstipation, 15.
Bill* salts, effects of, on lespiration, 383.

inHuenee of, on gastric function, 465.
Biliary obstruction not due to gall-stones, 127.

surgery, 125.
Biochemistry (abstracts), 84, 173, 273, 370,

408, 673..
Blackwater fever, 457.
Bladder, diverticula of, 184.
Blood after administration of urea, 277.

alkaline reserve of, in the insane, 277.

, changes in, in experimental in-
fections, 368.

appearance and distribution of fats and
lipoids in, after bleeding, 376.

carbon dioxide carriers of, 379.

coagulation of, role of calcium in, 558.

— theories of, 550.

concentration of lactic acid in, in anoxaemia

and shock, 376,
corpuscles, chemical composition of, 579.

— and plasma, distribution of {)hosphates
between, 469.

— , permeability of, to sugar, 86.

— , red, diurnal variation in size of, 366.

— , — , influence of certain digitalis bodies
on permeability to ions of, 174.

— , — , isoelectric point of, and its relation
to agglutination, 176.

~ , — , and outer fluid, distribution of glucose
between, 471.

— , — , rate of sedimentation of, 175.

— , — , rate of sedimentation of, during
pregnancy, 543.

— , — , structure of, 367.

^, — , volume of, and ratio of tliis volume
to haemoglobin and to number of cells,
365.

— , sedimentation of, 377.

— , simple procedure for accurate enumera-
tion of, without use of counting chamber,
364.

count of normal monkeys, 572.

— , white, of glycosurics, effect of glucose
on, 498.

counts, Biirker's method for, 277.

cultures, interpretation of, 458.

diastases in, source of, 469.

diastatic ferments of, 87.

diseases, classification of, 118

distribution of chlorides in, 88.

of dogfish, sand-shark, frog, and pigeon,
sugar in, 471-2.

effect on the composition of, of maintain-
ing an increased blood-volume by intra-
venous injection of gum acacia in normal,
asphyxiated, and shocked dogs, 273.

— of sweating and diuretics on, with diet
rich and poor in salt, 575.

— of surgical anaesthesia on reaction of, 6,7.
fat constituents of rabbit, variation of, 88.

Blood, fate of India ink injected into, 171.

ferment, studies of, in pregnancy, carci-
noma, and pulmonary tuberculosis, 162.

groups, distribution of, in patients suffer-
ing fiom ' maliginint disease', 461.

human, carbon dioxide dissociation curve
and arterial and venous carbon dioxide
tension of, in health and disease, 173.

paradoxical hyperalbuminosis in, of cancer
subjects, 466.

l)hosphates in lipaemia produced by acute
experimental anaemia in rabbits, 174.

as a physico-chemical system, 469.

picture in typhus, 196.

— in wliooping-cough, 202.

pressure estimation by indirect methods,

378.
— , action of irradiation on, 278.
— , arterial, measurement of, in horses, 279.
— , capillary, in man, measurement of, 160.
sugar regulation and origin of hyper-

glycaemias, 470.

— in diabetes, 502.
— , physiology of, 377.

— tolerance in gastro-intestinal carcino-
ma, 8.

suspension stability of, in pulmonary tuber-
culosis, 366.
use of Komanowsky type of stain for, 364.
vessels, experimental studies of properties
of surviving, under treatment with
chemical stimuli, 378.
volume, influence of injections of acacia-
glucose solutions on, 277.
Body-weight, effect of sweating and diuretics
on, with diet rich and poor in salt, 575.
Bone- marrow of rats exposed to 7 radiations
from radium, histological changes in, 93.
Bones, experimental investigations on in-
fluence of mechanical compression on,
369.
Bothriocephalus anaemia, 108.
Bolhriocephalus, complement fixation by the

hosts of, 163.
Botulism from cheese, 353.
Brachial plexus, anaesthesia of, 525.
Brain, basal arteries of, and their functional
significance, 348.
blood supply to, 323.
chemical composition of, in dementia prae-

cox, 479.
tumour, superficial, 446.
volume, experimental production of altera-
tions in, 535.
Bronchitis, fibrinous, 312.
Bulbo-pontine syndrome in typhi:s, 195.
Biirker's method for blood counts, 277.
Butter, effect of heat and oxygen on nutritive
value of, 84.

C. L. P. (malum coxae Calve-Legg-Perthes),
40.

Caecum, plication of, in treatment of consti-
pation, 227.

Calcium combination with animal tissues,
478.

Calomel, purgative action of, 180.

Calorimetric investigations on inanition and
deficiency disease, 167.

I. INDEX OF SUBJECTS

Cancer, abdominal, size of spleen in, 120.
of bile-duct, 129.

of breast, treatment of, by excision supple-
mented by radiation, statistics relating
to, 418.
of cervix, radium therapy of, 392, 584
grafts, effect of cellular reaction induced

by X-rays on, 488.
inoculation, influence of, on lymphoid
stimulation induced by small doses of
X-rays, 489.
melanotic, 229.
— , structure of, '233.

of oesophagus treated by direct application
of tube of radium emanation to oeso-
phageal wall through the transpleural
channel, 284.
patients, distribution of blood groups in,

461.
paradoxical hyperalbuminosis of blood in,

466.
primary, of lung, 317.

relation between time and extent of lym-
phoid stimulation induced by physical
agents and degree of resistance to, in
mice, 489.
of stomach, 7.

— , methods of diagnosis of, 92.
transplanted, effect of small doses of X-rays
of low penetration on the resistance of
mice to, 489.
see also names of particular forms of.
Capillaries, functional activity of, 278.
Capillary blood-pressure in man, measure-
ment of, 166.
Caramel in treatment of diabetes, 506.
Carbohydrate metabolism and diabetes, 86.

■ — of isolated amphibian muscle, 577.
Carbolic acid, use of, for isolating pathogenic
bacteria from material contaminated
with B. proteus, 80.
Carbon dioxide absorption curve and carbon
dioxide tension in blood of normal rest-
ing individuals, in cardiac dyspnoea,
and in severe anaemia, 381.
carriers of blood, 379.

dissociation curve and arterial and venous
carbon dioxide tension of human blood
in health and in disease, 173.
Carbon monoxide poisoning, 430.
Carcinoma, blood ferment in, 162.

of pancreas, 512.
Cardia, Rontgen obsei-vations on anatomy

and physiology of, 388.
Cardiac dyspnoea, carbon dioxide absorption
curve and carbon dioxide tension in,
381.
respiratory mechanism in, 382.
Cardiospasm, impermeable, treatment of, 15.
Carotid artery, 322.

arteriovenous aneurysm between, and
cavernous sinus, 424.
Cataract, action of radium in, 285.
Cavernous sinus, arteriovenous aneurysm

between, and carotid, 424.
Cell, auto-oxidizable constituent of, 573.
new experiments on uptake of substances
by, 478.
Cerebral metabolism, 476.

Cerebral softening from metallic embolus

in left middle ceiebral artei-y, 261.
thrombosis and embolism, 322.
tumours, localization or elimination of, by

ventriculography, 182.
Cerebrospinal fluid, constitution of, deciding

factor for prognosis and therapy in

syphilis of nervous system, 59.
in syphilis, 336.
general colloid test in, and use of Congo-

rubin, 479.
pi-essure, experimental alterations in, 535.
in typhus, 195.
in whooping-cough, 202.
Chancroid, 218.
Chaulmoogra oil, influence of, on tubercle

bacillus, 262.
Chloral hydrate solution, gargling with, in

treatment of influenza, 305.
Chloroma, colouring matter in, 579.
Cholecystectomy, mortality from, 126.
Cholecystitis, 127, 128.
Cholesterol content of serum, variation in, in

pneumonia, 87.
Choline, hormone of intestinal peristalsis,

479.
Chorionic ferments causing spirillolysis, 407.
Cicatrices, deformities of hands since child-
hood caused by, 482.
Citrus fruit juices, fresh, determination of

minimum doses of, which will protect a

guinea-pig from scurvy, together with

some observations on preservation of

such juices, 386.
Climatological studies : active factor in high

altitudes, 278.
Cobra venom, immunity to, 360.
Cocaine injections, danger of, 519.

into spinal theca, general analgesia bj', 522.
Cod-liver oil, effect of, on experimental rickets

in rats, 176.
Codein derivatives, acclimatization to, 180.
Colds, bacteriology of, 267.
Colectomy, 223.

Colitis, membranous, in influenza, 299.
ulcerative, a sequel to bacillary dysentery,

401.
Colloidal metals, bactericidal action of

secondary rays from, 94.
nutrient solutions, importance of, for nor-
mal, exhausted, and poisoned heart, 576.
Colloids, influence of, on non-colloidal drugs,

282.
Colon, symptoms due to extreme elongation

and dilatation of, 14.
Complement fixation by the hosts of Bothrio-

cephalus, 163.
test for gonorrhoea, 212.
Congo-rubin, use of, 479.
Constipation treated by bile enemata, 15.
Coolidge tube, danger of, for screen work, 394.
Coxalgia, non-tuberculous juvenile, 38.
Creatinin excretion, course of, in urine of

man, with especial reference to effect of

exercise, 180.
Creatinuria of man, diet and sex as factors

in, 469.
Crj'otherapy, 114.
Cylindromata of facial region, 467.

I. INDEX OF SUBJECTS

Cyst of common bile-duct, 128.
Cystic pneumatosis of intestine, 6.
Cystin, oxidation of, by blood charcoal, 480.
Cystitis after typhus, VJ6.
Cutaneous sensibility, semeiological impor-
tance of electrical examination of, 490.
Cutex vertieis gyrata, 114.

Deafness due to congenital syphilis, 411.
Decerebrate rigidity in man and occurrence

of tonic fits, 55.
Deficiency disease, calorimetric investiga-
tions on; 167.
Dementia praecox, chemical composition of

brain in, 479.
Dermatitis due to handling figs infected with
the mite Carpoglyphus passulanim, 113.
X-ray, followed by heat dermatitis, 391.
Dermatosis, precancerous, 114.
Diabetes, experimental, B. welchii infection
in, 275.
— , influence of cold in, 276.
— , influence of extreme age on production

of, 276,
— , influence of fever and intoxication in,

275.
— , influence of pregnancy on, 281.
— , studies in, 273.
mellitus, 497.
— , aetiology of, 497.
blood-sugar in, 502.
and carbohydrate metabolism, 86.
frequency of, in U.S.A., 498.
and hirsuties, 502.
and leukaemia, 501.
mortality from, 498.

pancreatic, relation of alkali reserve of
blood to glycosuria and hyperglycaeuiia
in, 173,
and pregnancy, 501.
prophylaxis of, 503,
renal, 502.

surgical complications of, 500.
symptomatology of, 498.
treatment of, 504,
and tuberculosis, 500.
Diabetic urine, acetaldehyde in, 576.
Diarrhoea, infantile, 12.
Diastatic ferments of blood, 87.
Diathermy in treatment of whooping-cough,

203.
Dicotyledonous plant, infection with, causing
Recklinghausen's disease, adenoma seba-
ceum, and tuberous sclerosis, 114.
Diet and growth, 386, 387.
Digestive tract, atonic syndrome of, in nervous

persons, 389.
Digitalis bodies, influence of certain, on per-
meability to ions of human red blood
corpuscles, 174.
Diphtheria, 18.
aetiology of, 18.
carriers and their treatment with mercuro-

chrome, 454.
diagnosis of, 24.
epidemiology of, 18.
immunity from, 26,

Diphtheria infections with particular reference
to carriers and to wound infections with
B. diphtheriae, 454.

of middle ear, 19.

of mouth, 19.

in the new-born, 21.

prophylaxis of, 25.

symptomatology of, 19.

treatment of, 27.

of umbilicus, 20.

of vulva, 20.

wound, 23.

— , bacteriology of, 162.

— , chemotherapeutic experiments with a
view to treatment of, 355.
Diphtheritic paralysis, 24.
Disodiumphosphate as a catalyst for quanti-
tative oxidation of glucose to carbon
dioxide with hydrogen peroxide, 178.
Disseminated sclerosis, aetiology of, 149.

experimental investigations on pathogene-
sis of, 347.

unusual motor symptoms in, with refer-
ence to differential diagnosis from epi-
demic encephalitis, 248.
' Dopa' test for tyrosinase, 230.
Drigalski-Conradi, influence of nutrose in

culture medium of, 77.
Drugs, acclimatization to. Acclimatization
to codein derivatives (eucodal and para-
codein), 180.
Duodenal diverticula : their clinical and
radiological aspects, 183,

perforation treated by duodenal alimenta-
tion, 15.

ulcer, 4.
Dupuytren's contraction, 52.
Dysenteric arthritis, 400.

forms, mixed, 456,
Dysenteriform catarrh due to flagellata, 399.
Dysentery, 399.

aetiology of, 399.

amoebic, 402,

bacillary, studies on epidemic of, 456.

— , aetiology of, 272.

— , sero-diagnosis in, 456.

— , in dog with simultaneous schistosomia-
sis, ankylostomiasis, and filariasis, 79.

bacilli, divisions of Flexner group of, 77.

bacteriology of, 57.

in children, 400.

diagnosis of, 403,

epidemiology of, 399,

gastric and pancreatic secretions in, 401.

historical, 399,

prognosis of, 403.

protozoan, epidemiological, and clinical
notes on, 456.

symptomatology of, 400,

treatment of, 403.

Eclampsia, biochemistry of, 537.
Eczema, aetiology and treatment of, 110,
Eichlofif-blue, use of, for isolating pathogenic

bacteria from material contaminated

with B. proteus, 80.
Elbow, anterior dislocation at, 41.
Electric currents, action of, on endocrine

glands and other tissues, 99.

Vlll

I. INDEX OF SUBJECTS

Electric currents, higli-frequency, plethysmo-
graphic investigations on effects of, 279.
mode of death by, 587.
Electro-diagnosis (abstracts), 490.
Electromyogram in nervous diseases, 530.
Electroradiology in neuritis of motor nerves,

492.
Electrotechnique (abstracts'!, 587.
Electrotherapy (abstracts), 99, 492.
Eisner's gastroscopy, practical value of, 439.
Embolism, cerebral, 322.
Emerods, 399.

Empyema, experimental streptococcus, 69.
Encephalitis, haemorrhagic, as complication
of dysentery. 402.
lethargica, differential diagnosis of, from

disseminated sclerosis, 248.
— , experimental study of, 148, 262.
— , experimental, transmission of, 65.
— , following typhus, 195.
— , microscopic observations on brains from

some cases of, 452.
— , psychiatric aspects of, 447.
— , special microscopic tinding in nervous

tissue from cases of, 452. .
— , treatment of medullary and radical

after-efi'ects of, 493.
— , winter incidence of, and seasonal re-
currence of chronic forms, 57.
neonatorum, 263.

and polyomyelitis, immunological dis-
tinctions of, 263.
Endocrine glands, action of electric currents

on, 99.
Endothelial reactions in tuberculosis, 375.
Endotheliomata of nasopharynx, 243.
Entamoeba macrolujalina, 457.
Enteritis, acute infectious, complicated by

polyneuritis, 12.
Enterococcus, properties and relations of,

257.
Enterostomy for post-operative intestinal

obstruction, 440.
Enzymes, proteoclastic, in normal and patho-
logical urine, 385.
Eosinophilia in sputum in asthma, 311.
Epilepsy, diabetic, 499,

following gun-shot wounds of skull, patho-
logy of, 448.
Epithelioma adenoides cysticum (Brooke) or
trichoepithelioma papillosum multiplex
(Jarisch), 464.
of skin, 114.
Erythrocytes : see blood corpuscles, red.
Erythromelalgia, 113.

Ether, intramuscular injection of, in treat-
ment of whooping-cough, 202.
Eustachian tube, intracranial extension of

sarcomata of, 242.
Evolution, neural, aspects of, 50.
Exophthalmos, pulsating, treated by ligature

of both common carotids, 426.
Eye diseases due to congenital syphilis,

melanoma and melanotic cancer of, 234.
simplified technique for radiotherapy of,
583.
Eyes, tonic labvriiitliine and neck reflexes
of, 151.

Fat, animal, effect on kittens of a diet

deficient in, 386.
content of embryonic livers, 88.
Fats, action of ozone on fat-soluble factor in,

85.
growth and nutrition on diets free from,

177, 178.
Fibrinolysis, 282.

Fibroid, pregnancy after radiotherapy for, 95.
Fibroids, uterine, radium therapy for, 285.
Fibromyoma tissue, chemical analysis of, 280.
Fibromyomata of uterus, intensive X-ray

therapy versus hysterectomy for, 95.
Flea-bites, liability of diabetics to, 500.
Flexner group of dysentery bacilli, divisions

of, 77.
Flies, action of, in spread of dysentery, 399.
Fontan's method of treating chancroidal

buboes, 220.
Foods, analyses and energy values of, 573.
Friedberger-van-der-Reis skin reaction in

diagnosis of typhus, 197.
Friedmann's tortoise liacilli, antigenic action

of, 261.

Gall-bladder, anatomy and physiology of, 126.

Gall-bladdei-s, pathological changes in 4,998
removed, 126.

Gall-stones, formation of, and detection by
X-rays, 127.
study of, by X-rays, 92.

Galleiia mellonella, immunity, natural and
acquired, in larva of, 82.

Gangrenous infections of animals, aetiology
of acute : a discussion of blackleg, braxy,
malignant oedema, and whale septic-
aemia, 160.

Gas cysts of abdomen, 10.

phlegmon following subcutaneous in-
jections, 568.

Gasoline vapour, anaesthetic and convulsant
effects of, 280.

Gastric analysis, 3, 474.

angioma, 10.

function, influence of bile salts on, 465.

myomata, 10.

polyposis, 9.

and respiratory response to meals, 466.

secretion and motility, effects of restricted

(so-called ulcer) diets on, 15.
secretions in bacillary dysentery, 401.
— in starvation, 473.
ulcer, 4.

see also stomach.
Gastrin, response of stomach glands to, before

and shortly after birth, 474.
Gastro-intestinal liaemorrhage, 11.

tract, X-ray interpretation of, 389.
Gastroscopy, Eisner's, 439.
Gastrospasm, reflex, 129.
Gaucher's disease, 119, 170.
Gentian violet reaction, 91.
Giant cells in cultures from human lymph

nodes, 370.
Gigantism, experimental production of, by
feeding anterior lobe of hypophj-sis and
jiituitary gland, 179.

I. INDEX OF SUBJECTS

Globin, antigenic properties cf, with a note
on tlie indopciidence of properties of
serum and tissue proteins as exemplitiod
by absence of antibody from globin of
an immunized animal, 1(55.
Glycaemia, adrenalin, 576.
Glycogenic infiltration of liver of laboratory

rabbits, 67.
Glycosuria, association of, with infections

diseases, 497.
Gonococcal infections of the heart, 211.

septicaemia, 210.
Gonococci, serological investigations on, 450.
Gonococcus, growth of, in various gaseous en-
vironments, 256.
relative toxicity of different strains of,

210.
types of, 157, 257.
Gonorrhoea, 210
aetiology of, 210.
chronic, in women, comparison of smear,

culture and complement fixation, 157.
diagnosis of, 212.
in the female, 214.
prostitution and alcoli'l in causation of,

210.
symptomatology of, 210.
treatment of, 214.
Gout, roentgenographic studies in, 484.
Grafts of dead tendon, 527.
Gram reaction, parallelism between, and

gentian violet reaction, 91.
Graves's disease, 341,

use of radiotherapj' in, 390.
thyroid lesions in, 247.
Growth on diets poor in true fats, 177,
Growth-promoting properties, comparison of,
for guinea-pigs, of certain diets consisting
of natural foodstuffs, 386.
Gum acacia injections, temperature changes
induced by, in normal and fevered
animals, 90.

Haemagglulination, its medico-legal bearing,
with observations upon the theory of
isoagglutinins, 163.

Haematology, employment of complex stains
based on Romanowsky principle in, 364,

Haemato-respiratory functions. An irre-
versible alteration of HXCj NaHCO.
equilibrium of blood induced by tem-
porary exposure to a low tension of CO^,
174.

Haemoglobin, reduced, light absorption of,
876.
variable acidity of. 88.

Haemolysin, anti-human, production of, with
special reference to immunization with
erythrocytes sensitized with heated
serum, 165.

Haemolysis, 367.

Haemolytic sensitizer and red blood cor-
puscles, equilibrium between, in relation
to H-ion concentration, 378.

Haemophilic bacilli, biological study of, 154.

Haemorrhage following acute septic infection,
325.
following removal of tonsils, 326.

Haemorrhage from carotid and vertebral
arteries following gunshot wounds, 328.
reactions to, 470.
Haemotoxin of streptococci, biological and

physical properties of, 69.
Hay fever, aetiology and treatment of, 309.
Heart, effects of warming; and cooling sino-
auricular node in, 472.
failure in diphtheria, 23.
fibrillation of, 472.
gonococcal infections of, 211.
isolated, frog's, effects of some chlorine
derivatives of methane, ethane, and
ethylene on, 472.
perfused, researches on, 280.
Heat regulation of mammals, chemical, 378.
Hemiplegia following ligature of common
carotid, 324.
following tonsillectomy, 327.
pleuritic, 319.
Hepatic function in eclanijjsia, 539.
'd'Herelle phenomenon,' some peculiarities

of, 74.
d'Herelle's bacteriophage, 74.

bacteriophage, production and interpreta-
tion of, 62.
Hernia, superficial inguinal, 241.
Hernias, large umbilical and ventral, treat-
ment of, 239.
Herpes, virus of, 451.

zoster, 112.
Hibernation, artifical, in mice, 378.
Hirsuties in diabetics, 502.
Histamin, action of, on man, 580.
Honey, vitamine content of, 468.
Hookworm infection : see ankylostomiasis.
Hydatid cysts of kidney, pyelography in

diagnosis of, 287.
Hydrocephalus due to occlusion of foramina
of Magendie and Luschka, diagnosis and
treatment of, 549.
Hydrogen electrode, probable error in deter-
minations by means of, 255.
Hydrogen-ion concentration of broth media,
variations in, 566.
equilibrium between haemolytic sensitizer

and red blood cells in relation to, 378.
relation of, to growth, viability, and
fermentative activity of Streptococcus
haemolyticus, 565.
Hyperacidity, 4.

Hyperglycaemia, difference between the
mechanism of production of, by ether
and chloroform, 274.
Hyporglycaemias, origin of, 470.
Hypertrichosis, electrolysis treatment of, 114.
Hypophysis, anterior lobe of, experimental
gigantism produced by leeding, 179.
radiotherapy of tumours of, 582.
treatment of tumours of, by actinotherapy,
486.
Hypopyon complicating typhus, 196.
Hysteria, anxiety, 349.

Icterus neonatorum, breaking down of ma-
ternal blood as cause of, 580.

Ileo-sigmoidostomy, 140.

Immune bodies, specific, transmission of,from
mother to young, 164.

I. INDEX OF SUBJECTS

Immunity to cobra venom, natural and ac-
quired, 3G0.

natural and acquired, in lai-va of Galleria
mellonella, 82.
Inanition calorimetric investigations on,

167.
Induction coils, action of, 181.
Infants' foods, digestion of, 387.
Influenza, 295.

aetiology of, 155, 296, 563.

— : experiments in search of filter-
passing virus, 66.

association of with whooping-cough, 201.

bacillus : see B. injluensae.

bacteriology of, 267, 562.

blood in, 296.

in children, 303.

chronic lung disease following, 297.

and common colds, attempt to cultivate
filterable viruses from, 264.

disease resembling, produced in monkeys
by inoculation with B. in/luejtsae, 153.

epidemiology of, 295.

immunity against, 303.

nervous and mental complications of, 299.

in old age, 303.

pathology of, 264, 562.

prophylaxis of, 304.

renal complications of, 299.

skin in, 300.

studies of the nasopharyngeal secretions
from patients, 266, 560.

surgical complications of, 300.

symptomatology of, 297.

and syphilis, 302.

transmitted through fleas, 296.

treatment of, 305.

and tuberculosis, 301.

vaccination against, 564.
Integrative action of nervous system, 144.
' Intertraction ' between albuminous .sub-
stances and saline solutions, 577.
Intestinal exclusion, 137.

infection, non-specific, 12.

obstruction caused by ascarides, 104.

— , post-operative, enterostomy for, 440.

parasites, 103.

— , frequency in young children, 103.

stasis, chronic, surgical treatment of, 221.
Intestine, the anaerobic flora in some morbid
states of, 159.

fate of micro-organisms introduced into
isolated loops of, 79.

large, results of operations for atony and
prolapse of, 223.

of small herbivora, flora of, 76.
Intracranial tension, alteration of, by salt

solution in alimentary canal, 178.
Iodine, biochemistry of : comparative effects
of thyroid and iodide feeding on growth
in white rats and in rabbits, 179.

compounds, specific, influence of, upon
metamorphosis of frog's larvae and axo-
lotl, 578.
Ipecac, sensitization and bronchial asthma,
310.

von Jaksch syndrome, 119.

Jaundice complicating gonococcal septi-
caemia, 211.
haemolytic, 122.

— , caused by Ascaris lumhricoides, 105.
in influenza, 299.
occun'ing after re vaccination in adults, 209.

Keratin, composition of, 110.

Keratodermia blenorrhagica, complicating

chronic gonorrhoeal arthritis, 212.
a form of psoriasis, 110.
Kidney, pyelography in diagnosis of hydatid

cysts of, 287.
Kidneys, radiological examination of, after

intraperitoneal insufflation, 286.
Knee-jerk, relation of form of, to muscle

tonus, 54.
Kiihler's disease, 483.
with special reference to its aetiology, 345.

Labyrinthine reflexes to progressive move-
ments, 151.

Lactation, influence of, on sexual cycle in rat
and guinea-pig, 475.

Lactic acid in blood in anoxaemia and shock,
376.

Lard, nutritive value of, 85.

Larynx, treatment of cancer of, by local ap-
plications of radium, 285.

Lecithin of brain, 473.

Leiomyoma of smooth muscle-cells of arrec-
tores pili, 114.

Leprosy, histopathology of, 372.

Leuco-agglutinins, 461.

Leucocytes, changes in, in experimental in-
fections, 368.

Leucocytic exudates and transmissible bac-
terial autolysin, 62.
formula, normal, 169.

Leucocytolysis produced by rontgenization of
spleen, treatment of infectious diseases
by, 485.
chemotactic effect of osmosis upon, 362.

Leukaemia, action of X-rays in, 486.
acute, in pregnancy, 64.
and diabetes, 501.

transmissible, new strain in fowls (strain
H), 572.

Leukoplacia treated with carbon dioxide
snow, 114.

Lice, importance of, in transmission of typhus,
194.

Lichen and lichenification. 111.

Light baths, universal, in treatment of eye
diseases, 346.

Linitis, plastic, 4.

Lipaemia in acute anaemia, 88.
chemistry of, 376.

Lipoid granules, special staining method for,
in nerve-cells, 252.

Liver, artificially perfused, experiments with
antigens and antibodies upon surviving,
388.^
composition of, in acute yellow atrophy,
479.

Luetin reaction, value of, in diagnosis of con-
genital syphilis, 412,

I. INDEX OF SUBJECTS

Lumbago, origin and symptomatology of,

349.
Lumbar puncture, troubles due to, 521.
Lung, congenital absence of, 309.

chronic disease of, following influenza, 297.

gangrene of, 316,

infection, non-tuberculous, 313.

new growths of, 317.

see also pulmonary.
Lupus erythematosus, 112.

vulgaris, treatment of, witli liquid acid
nitrate of mercury, 112.
Lymphadenoma with pruritus, 114.
Lymphocytes, fate of, 572.

Malta fever, prophylactic vaccination against,
256.

Mammary gland, laetating, effect of suckling
and castration on, in rat and guinea-pig,
474.
secretion, effect of diet on, 387.

Manchester and district Radium Institute,
report of, 283.

Measles, experimental, symptomatology and
pathology of, in monkeys, 354.
susceptibility of monkeys to, 354.

Media, influence of reaction of, and of pre-
sence of buffer salts on metabolism of
bacteria, G6.
reaction of, 564.

Melanin, 229.

Melanoblastoma, 229.

Melanogen in urine, 229,

Melanoma, 229.
structure of, 233.

Memorial Hospital, New York, radium tech-
nique at, 290.

Meniere's disease, symptoms of, complicating
influenza, 301.

Meningitis, serous, post-traumatic, in chil-
dren, 253.

Meningococcal infection, certain problems
concerning, 258.

Meningococci, serological investigations on,
450.

Meningococcus : experimental studies of mode
of action of antimeningococcal serum, 63.
production of antimeningococcic serum,
81, 82.

Meningo-encephalitis, haemorrhagic, in
anthrax, 161.

Mercurochrome in treatment of diphtheria
carriers, 454.

Mesothelioma of pleura, 319.

Metabolism, bacterial, 90.

general water, secretion of water by kidney
in relation to, 575.

Methylene blue in treatment of gonorrhoea
in women, 216.

Microbic species, dissociation of, 568.

Milk, condensed, full cream, sweetened,
investigation of antiscorbutic value of,
by experiments on monkeys, 387.
deficiency of heat-treated, 85.
dried, antiscorbutic value of, 387.
influence of diet of cow upon nutritive and

antiscorbutic properties of, 177.
powders, antiscorbutic potency of, 468.

Milk, vitamine content of, 84.

Morgan's bacillus, 271.

Motor system, extrapyramidal, organization

of, 443.
Multiple sclerosis and psycho-analysis, 441.
Muscle, carbohydrate metabolism of isolated

amphibian, 577.
influence of subminimal stimuli npnn

course of chemical changes in, 577.
tune, nature of, 532.
Mustard gas, effect of, on antibod ,

369.
effect of, on experimental tuberculosis, 369.
Myelitis in dysentery patient, 402.
Myeloma of spine, 250.
Myiasis cured by excision, 114.
Myocardial involvement, post influenzal, 298.
Myomata, gastric, 10.

Naevus derived from branchial clefts, 114.
warty, in lieredo-syphiliMc subject, 410.
Necator americanns in India, 106.
Neosalvarsan, splenomegaly following injec-
tion of, 122.
in treatment of congenital sypliilis, 414.
Nerve-cells of parietal plexuses of gastro-
enteric canal, lesions of, in consequence
of surgical interventions, 371.
lesions in early syphilis and their treat-
ment, 61.
and plasmodesma, 445.
regeneration, 351.

root fibres, posterior, intramedullary bifur-
cation of, in man, 549.
section in man, experimental, results of, 46.
tissue, cultivation of, 351.
Nervous diseases, electromyogram in, 530.
system, dissolution of function in disease

of, 141.
— , elementary, physiology of, 141.
— , insulation of, 48.

and mental complications of influenza, 299.
Neuritis of motor nerves, electroradiology in,

492.
Neuroglia fibres, quick process for staining,

168.
Neurology (abstracts), 53, 146, 242, 347, 441,

547.
Neurosyphilis, 335.

constitution of cerebrospinal fluid in prog-
nosis of, 59, 60.
increased incidence of, 335.
intraspinal treatment of, 338.
prognosis and therapy of, 59, 60.
relation of, to previous treatment, 335.
Novarsenobenzol in treatment of congenital
syphilis, 416.
— of diabetes, 506,
Novocaine and bicarbonate solution, toxic
effects of injection of, into a vein, 518.
as local anaesthetic, disadvantages of, 520.
Nutrition, 468.

in diets practically devoid of fat, 178.
Nutrose, influence of, in culture medium of
Drigalski-Conradi, 77.

Obesity preceding diabetes, 503.

XII

I. INDEX OF SUBJECTS

Oculo-cardinc nliex (Daguini-Aschner phe-
nonitiuon) — its use in medicine and
psychology, 150.

Oesophagus, treatment of cancer of, by local
applications of radium, 285.

Oils, hydrogenated, digestibility of. 282.

Oleic acid and trioleins, haemolytic action of,
in rabbits, 160.

Onychodystropliy following typhus, 195.

Opacity of liquids, methods of measuring,
580.

0|>hthalmia and diet, 574.

Oj)lithalm(>l<igy, universal light baths in, 346.

Orchilytic sera, sexual neutralization obtained
by means of, 1()9.

Oriental sore, treatment of, with X-rays,
114,

Osmosis, chemotactic effect of, on leucocyto-
sis, 362.
as factor in local accumulation of leuco-
cytes in body, 90.

Osteoarthropathy, hypertrophic pulmonary,
following lung abscess, 315.

Osteochondritis deformans juvenilis, 39.
of upper epiphysis of femur, 39, 481.

Osteolysis, 372.

Osteomyelitis of hy<>id after influenza, 301.

Otoliths, functions of, 152.

Ovariolytic sera, sexual neutralization ob-
tained by means of, 169,

Oxalic acid, determination of, in urine and
faeces, 473.

Oxaluric acid, determination of, in urine and
faeces, 473.

Oxygen administration, effects of, in decere-
brate cats, 383.
low, effects during rebreathing, 382.
subcutaneous injections of in treatment of
influenzal broncho-pneumonia, 305.

Oxyuriasis, tongue sign in, 103.
of vermiform appendix, 105,

Oxyuris vermicular is , prevalence of, due to war,
105.

Paget's disease, extra-mammary, 114.
Pain, frequency of, 44,

functional value of, 44.

physiology of, 43.

relation of, to bodily cause, 44.

— , to other forms of sensation, 50.

sensibility to, in skin, 45.
Pancreas, annular, 509.

atrophy of, 511.

carcin>jnia of, 512.

cirrhosis of, 511.

diseases of, 509.

— , diagnosis of, 514.

necrosis of, 510.

syphilis of, 511.
Pancreatic achylia or hypochylia, 511.

calculi, 513.

secretions in bacillary dysentery, 401.
Pancreatitis, chronic, 510.
Pangenesis, 74.
Paragglutination, 355,
Paralyses of pyramidal origin, selective

incidence of, 443.
Paralysis, diphtheritic, 24.

Para-nieningococci, serological investigations

on, 450.
Paraoxyphenylacetic acid, formation of, from

laevo-tyrosin by bacteria, 473.
Paraoxyphenylacrylic acid, formation of,

from laevo-tyrosin by bacteria, 473.
Parathyroid secretion, stability of nervous

system as factor in resistance of albino

rat to loss of, 475.
tetany, relation between, and calcium

deficit in blood, 278.
Paratyphoid B bacillus related to rodent

group, spontaneous epidemic among

laboratory rabbits caivsed by, 80.
Paravertebral injections, 523.
Parosmia, 281.

Parotid swelling due to denture, 3.
Patellar clonus, relation of, to muscle tonus,

54.
Pathology (abstracts), 57, 152, 255, 352, 450,

550.
Pellagra, 113.

sulphocvanate content of saliva and urine

in, 283.
Pericolitis membranacea, 226.
Periodic breathing of decerebrate cats, 383.
Periodicity of gastric ulcer, 6.
Peripheral nerves, insulation of, 49,
Perspiration, in.sensible, through cutaneous

scars and skin of paretic limbs, 370,
Petro-sphenoidal junction, syndrome of, 242,
Phagedaena, development of, in vaccine

pustule, 208,
Phagocytes, mononuclear, of lung, experi-
mental study of, 462,
Phagocytosis, action of certain salts on, 361.
experimental investigations on, iniiueuce

of various fixing agents, fatigue and

diluted solutions of HCl, 171,
investigations on, 460,
of solid particles, 478,
Phenolic substances, estimation of, in urine,

86.
Phenolphthalein, purgative action of, 180,
Phosgene poisoning, experimental pathology

and therapy of, 384,
Phosphates, distribution of, between blood-
corpuscles and plasma in vivo and in vitro,

469.
Physical exertion, fitness, and breathing, 280,
Pilomotor reflex, 246.
Pituitary body, secretory activity of anterior

lobe of, during pregnancy, 371,
gland, experimental gigantism produced by

feeding, 179,
opotherapy of diabetes, 507.
Plague, experimental investigations on im-
munity of rats against, 459.
complement fixation test for diagnosis of,

361.
means of importation of, into Italy and

preventive measures, 459.
Plasmodesma and nerve, 445.
Pleura, new growths of, 319.

removal of particulate matter from, 462.
Pleural effusions, encapsuled, radiological

appearances of, 581.
Pleurisy, mediastinal, 318.
parabronchial, 318.

I. INDEX OF SUBJECTS

xni

Pleuritic hemiplegia, 319.
Plumliisni cansiiij; jjastric ulcer, 5.
Pneumatosis, intestinal, 10.
Pneumobacillus causing pulmonary abscess,

315.
Pneumococt'i from the upper respiratory
tract, serological relationships of, with
special reference to common colds and
influenzal conditions, 267.
types of, 73.
I'neumococcus, enzymes of, 71,
Pneumonia, experimental, 153.

influenzal, pathological-anatomical and

bacteriological study of, 502.
variation of cholesterol content of serum in,
87.
Pneumonomycosis a.speigillina after influ-
enza, 298.
Pneumothorax, experimeiilal and critical
studies on. 570.
determination of volume of pleural cavity

in course of, 571.
spontaneous, 319.
Poliomyelitis, acute, 146.

and encephalitis, immunological distinc-
tions of, 263.
transient, following influen/a, 300.
Polj'cythaemia hypertonics, gastro-intestinal
haemorrhage in, 11.
radiotherapy of, 390.
Polyposis, gastric, 9.

Precipitin response in blood of rabbits fol-
lowing subarachnoid injections of horse
serum, 569.
test for gonorrhoea, 213.
Piegnancy after radiotherapy for fibroid, 95.
ammonia coefficient of, 89.
blood ferment in, 162.
and diabetes, 501.
toxaemias of, 537.
Pressure, low, physiological effects of short

exposures to, 174.
Protein meal given to a man at end of 8-day
fast, effect of, 86.
non-specific, in treatment of gonorrhoea!

arthritis, 214.
production of fat from, 86.
racemization, comparative investigation
of corresponding proteins of cow and ox
. serum, cow's colostrum and cow's milk

by method of, 575.
Proteinogenous amines, biological effect of,

578.
' Protopathic ' animal, 142.
Pseudo-ascites in children, 13.
Pseudo-coxalgia, 39.
Psoriasis an infective disorder, 110.

post vaccinal, 208.
Psycho-analysis and multiple sclerosis, 441.
Psychology and psychotherapy, 245.

of special senses and their functional dis-
orders, 53.
Psychotherapy, 245.
Pulmonary abscess, 314.
aspergillosis, 317.
congestion in typhus, 195.
lesions, spontaneous and artificial, in

guinea-pigs, rabbits, and mice, 154.
radioscopy and radiography, 581.

Pulmonary streptothricosis, 316.

suppuration, circumscribed, clinical history

of, 581. .
See also lung.
Pupil dilatation, paradoxical, following

lesions of afferent paths, 550.
Pyelitis larvata cystalgica, 240.
Pvelofjrapliy in diagnosis of hyd.itid cysts of

kidney, 287.
Pyloric spasm , 6, 184.
Pyrimidine metabolism, 89.

Quartz lamp in treatment of rectal lesions

following dysentery, 404.
ultra-violet therapy and kinetic energy,

391.
Quinine salts, local anaesthesia by, 520.

Radiations, some problems in biological

action of, 185.
Radiobiology (abstracts), 93, 185, 395, 487,

585.
Radiodiagnosis (abstracts), 92, 182, 286, 389,

481,581.
Radiology and electrology (abstracts), 92, 181,

283, 388, 481, 581.
Radiotechnique (abstracts), 181, 290.
Radiotherapy (abstracts), 95, 287, 390, 485,
582.
deep, in internal medicine, 487.
prolonged diffuse sclerosis of skin and of
cellular tissue of neck following, 391.
Radium, bactericidal action of, on B. piju-
cyaneus, 187.
emanation, disturbances in "'evelopment of

mammalian embryos caused by, 90.
— , effect of, on brains of animals, 585.
— , response of animal organism, to re-
peated injections of an active deposit of,
185.
histological changes in bone-marrow of rats

exposed to y radiations Irom, 93.
Institute, report of work carried out at,

during 1919, 96.
red cell content of those handling, for

therapeutic purposes, 93.
similarity of results produced by vitamines

and, 466, 487.
therapy (abstracts), 96. 283, 392, 583.
Ramus communicans, first white thoracic, in

man, 446.
Rat plague, epidemiological and anatomo-

pathological observations on, 459.
Rat-bite fever, cases of, 271.
Rays, ultra-violet, visible spectrum, infra-red,
phenomena of antagonism between, 395.
Reaction of biological media, 564.
Recto-colitis, severe forms of, 12.
Recurrent laryngeal nerve, paralysis of, 254.
Reflex, jiilomotor, 246.
Reflexes, ' conditional ', 428.

labyrinthine, 151.
Regression, numerical law of, of certain sex

characters, 179.
Renal complications of influenza, 299.
function in eclampsia, 539.

XIV

I. INDEX OF SUBJECTS

Resorcin, intravfiious injections of, in treat-
ment of influenza, 305.
Respiration, forced, and tetany, 431.

physiology of, 382, 383.
Respiratory exchange of surviving mouse
tissues, normal and neoplastic, 68.

diseases, 309.

infection, acute, microbial studies on, with
especial consideration of immunological
types, 267.

quotient and its uncertainty, 883.

tract, infections of, 267.
Rotinitis, albuminuric, 500,

diabetic, 499.
Reviews.

Active suppuration about tlie wrist treated
by incision dividing the annular liga-
ment, 236.

Alimentary diseases, 3.

Anterior dislocation at the elbow, 41.

Biliary surgery, 125.

Biochemistry of eclampsia, 537,

Carotid and vertebral arteries : haemo-
rrhage and aneurysm : cerebral throm-
bosis and embolism, 322.

Chancroid, 218.

Congenital syphilis, 406.

Congenital torticollis, 132.

Diabetes mellitus, 497.

Diphtheria, 18.

Diseases of the pancreas, 509.

Diseases of the respiratory system, 309.

Diseases of the skin, 110.

Disea.ses of the spleen, 118.

Dysentery, 399.

Electromyogram in nervous diseases, 530.

Experimental production of alterations in
brain volume, 535.

Gonorrhoea, 210.

Grafts of dead tendon, 527.

Influenza, 295.

Injury causing spasmodic contraction of
segments of arteries of medium size, 33,

Intestinal exclusion, 137,

Intestinal parasites, 103.

Melanin, melanoma, melanotic cancer, 229.

Neurosyphilis, 335.

Non-tuberculous juvenile coxalgia, 38.

Physiology of elementary nervous system,
141.

Physiology of pain, 43.

Post-mortem examination of a case of
arteriovenous aneurysm between the in-
ternal carotid artery and the cavernous
sinus, 424.

Role of anoxaemia in the production of
symptoms in disease and injury of the
nervous system, 427.

Spinal, regional, and local anaesthesia,
516.

Statistics relating to the treatment of cancer
of the breast by excision supplemented
by radiation, 418.

Surgical treatment of chronic intestinal
stasis, 221,

Typhus, 191.

Vaccination, 205.

Whooping-cough, 201.
Rickets, aetiology of, 465, 574.

Rickets, dietaries of infants in relation to
development of, 176.
experimental, production of, in rats by de-
ficient diets, 176.
— , in rats, effect of cod-liver oil on, 176.
Rigor mortis in smooth muscle, 280.
Ringworm, differential diagnosis between
large- and small-spored, 112.
X-ray therai^y of, precautions to be taken
in, 112.

Sachs-Georgi syphilis reaction, 361.
Sacral anaesthesia, 625.
Saliva in diabetic patients, 499.
Salvarsan, sources of error in treatment by,
158.
in treatment of pulmonary gangrene, 316,
Saphenous vein, internal, primary sarcoma

of, 345.
Saponin, effects of, on respiration, 383.
Sarcoid of Boeck-Darier treated by intra-
venous injection of salvarsan, 114.
Sarcoma following radium treatment of
epithelioma of tongue, 583.
primary, of internal saphenous vein, 345,
primary, of stomach, 9.
of spleen, 120,
Sarcomata of Eustachian tube, 242,
Scabies, 113.

Schmitz, bacteriology of bacillus of, 78.
Sciatica, pathogenesis of. 254.
Sclerodermia, affections o# joints in, 113.
Scurvy, protection against, 386, 387.
Secretin, supposed identity of, with water-
soluble B vitamine, 468.
Senses, special, psychology of, 53.
Sepsis, chronic, of skin, treatment of. 111,
Septicaemia, gonococcal, 210.
Sera, concentrated, action of, 166.
Serum treatment of chancroid, 220.

treatment of gonorrhoea, 216.
Sham feeding test, 4.

Shick test for susceptibility to diphtheria, 25.
Shock, experimental, basal metabolism in :
oxygen content and chemical changes in
blood in, 275.
lactic acid in blood in, 376.
Silver nitrate solution, use of, for painting
throat in treatment of pertussis, 203.
oligodynamic action of, 480.
salvarsan in treatment of congenital syphi-
lis, 416.
Skin, diseases of, 110.
in influenza, 300.
pigmentation of. 111.
sensibility to pain of, 45.
Skull, pathological physiology of, 428.
Smell, theory of, 281.

Sodium bicarbonate, relationship between
plasma bicarbonate and urinary acidity
following the administration of, 173.
— , solution, intraperitoneal administration

of, 480.
iodide, intravenous injections of, in treat-
ment of gonorrhoeal arthritis, epididy-
mitis, and prostatitis, 214.
lactate in treatment of diabetes, 506.
Soil bacteria, the size of spores of, 159,

I. INDEX OF SUBJECTS

Soil bacteria, a new anaerobic bacillus of

(B. spertnoides), 160.
Soy bean flour, nutritive value of, as a sup-
plement to wheat flour, 468.
Spasmodic contraction of arteries of medium

size caused by injury, 33.
Spastic gait, treatment of, by permanent
flexion of great toe, 548.
paralysis, condition of extensor muscles in,
533.
Spectrum, antagonistic properties in different

regions of, 396.
Spermatozoa, physical and chemical proper-
ties of horse semen in relation to physi-
ology of, 477.
Spinal anaesthesia, 520.

cord, posterior column of, myelinization

of, 547.
ganglion-cell, human, growth-curve of,

371.
reflex mechanism, effects of anoxaemia on,
428.
Spine, cervical, congenital anomalies of, 342.

myeloma of, 250.
Spirillolysis by chorionic ferments, 407.
Spirocliaeta icterohacniorrhagiae, Sp. iderogenes,

and Sp. hebdomadis, relations of, 455.
Spirochaetes, buccal, beneficial effect of cer-
tain bacteria in cultivation of, 270.
in lymphatic glands, 58.
Spirochaetosis, bronchial, 313.

ictero-liaemorrhagica, dual histopathologi-
cal character of, relation with acute
yellow atrophy of liver, 374.
spontaneous, of rabbit, 569. •
Spironemata of pointed condylomata, 158.
Splanchnic anaesthesia, 524.
Spleen, abscess of, 119.
diseases of, 118.

size of, in abdominal cancer, 120.
Splenectomy, indications for, 124.
Splenomegaly, various forms of, 121.
Spores, heat resistance of, 352.
' Staphar ' in treatment of chronic sepsis of

skin, 111.
Staphylococci, activity of, in milk, 256.
Steaton-hoea, congenital, 509.
Stegomyia, period during which, can live at

low temperatures, 477.
Stomach, cancer of, 7.

perforation of, in gastric cancer, 8.
primary sarcoma of, 9.
ulcer of smaller curvature of, 182.
see also gastric.
Streptococci, faecal, properties and relations
of, 257.
green producing, respiratory infections

with, 267.
haemolytic, of vermiform appendix, 257.
haemotoxin of, biological and physical

properties of, 69.
virulence of, action of certain salts on, 361.
Streptococcus empyema, experimental. II.

Attempts at dye therapy, 69.
Streptococcus haernolyticus, biochemistry of, 565.
infection, effect of, on reaction of blood of
rabbits, 69.
Streptothricosis, pulmonary, 316.
String test in diagnosis of peptic ulcers, 6.

Suggestion, 244.

Sulphur, purgative action of, 180.

Supraronin solution, immediate death from

injection of, 518.
Surgery (abstracts), 52, 239, 341, 435.
Swine erysipelas in man, bacteriology of, 352.
Syphilis, antenatal, 406.

behaviour of cerebrospinal fluid in, 336.
congenital, 406.
— , change of type in, 410.
— , diagnosis of, 412.
— , symptomatology of, 410.
— , treatment of, 414.
of eighth nerv<>, 447.

experimental, superinfection in, following
the administration of subcurative doses
of arsphenamine or neoarsphenamine,
570.
and influenza, 302.
of nei-vous system, 59, 60, 61.
of pancreas, 511.

results of antenatal treatment of, 413.
Sachs-Georgi reaction in, 361.
transmission of, to third generation, 412.
value of gland puncture in early diagnosis

of, 59.
visceral, mistaken for duodenal ulcer, 6.
Syphilitic infection, attenuation of virulence
of, in pregnant women, 407.
aortitis, gastro-inte.stinal haemorrhage in,
11.

Tabes, behaviour of cerebrospinal fluid in,
337.
essential lesion of, 547.
histopathology of, 547.
juvenile, 149, 411.

mesenterica following influenza, 302.
Taenia cucumerina in infants, 103.
Tar cancer, 114.
Tarsal scaphoid, inflammation of, in young

children (Kohler's disease), 483.
Temperature changes induced by gum acacia
injections in normal and fevered animals,
90.
Tendon, dead, grafts of, 527.

reflexes, function of, 531.
Testicle, changes in inter.stitial tissue of, in
consequence of deficiency of water-soluble
accessory substance B, 168.
Tetanus toxin, effects of, on artificially per-
fused liver, 388.
Tetany and forced respiration, 431.
Thiodiglycol, poisonous effect of, upon urease,

179.
Thrombopenia, splenogenous, 124.
Thrombosis, cerebral, 322.
Thrush fungus, 262.
Thyroid apparatus, 475.

effect of small amounts of, on size and
weiglit of certain organs in male white
rat, 280.
gland, distribution of iodine between cells

and colloid in, 475.
and iodide feeding, comparative effects of,
on growth in white rats and rabbits, 179.
lesions of, in Graves's disease, 247.
Tobacco smoke as disinfectant of mouth, 357.

XVI

I. INDEX OF SUBJECTS

Tonic fits, 55.

Tonsil, relation of, to blood-vessels, 324.
Tonsils, methods of removing, 326.
Torticollis, congenital, 132.
Trachoma, exp«»riniental. 462.
Trauma and diabetes, 497.
Trichocephaliasis, 107, lOS.
Trichophytic infection, production of anti-
bodies in, 112.
Trichophytosis complicating vaccination, 208.
Tryptophane, colorimetric experiments on,

579.
Tubercle bacilli, attenuated, antigenic action
of, 261.
comparative value of methods of Herman

and Ziehl-Neelsen for staining, 83.
fat content of, 559.

human and bovine, facultative acid fast-
ness in, 260.
search for, in cold abscesses, suppurative
glands, and urines, 559.
Tubercle bacillus, cultivation of, in glycerine-
free media, 261.
influence of chaulmoogra oil on, 262.
Tuberculin hypersensitiveness in non-tuber-
culous guinea-pigs induced by injections
of bacillus-free filtrates, 558.
use of, in lupus erythematosus. 112.
Tuberculosis, active, diagnosis of, by Wild-
bolz's auto-urine reaction, 559.
articular, surgical treatment of, 438.
in bones and joints, i"adiological diagnosis

of, 481.
of calcaneus in children, 482.
cutis vegetans, 112,
and diabetes, 500.
endothelial reactions in, 375.
experimental, effect of mustard gas on,

369.
— , mercury compounds in chemotherapy

of, in guinea-pigs, 262.
influence of exposure to X-rays on the

gro%vth of, 395.
and influenza, 301.
osseous, surgical treatment of, 438.
pulmonary, blood ferment in, 162.
— , suspension stability of blood in, 366.
of spleen, 120.
spontaneous, in frog, 84.
surgical, 435.
— , actinotherapy of, 437.
Tuberculous sputa, homogenization of, 559.

guinea-pigs, weight curves of, 82.
Tumours of basal ganglia, mental disturb-
ances in, 447.
of hypophysis, radiotherapy of, 582.
malignant, clinically obscure, of naso-
pharyngeal wall, 242.
mixed, of facial region, development of so-
called, 467.
of scalp containing brain tissue, 114.
superficial of brain, 446.
Typhoid fever patients treated with a hetero-
logous (anticholera) vaccine, haemato-
losjical and serological investigations on,
356.
Typhus, 191.

in association with other diseases, 196.
aural and laryngeal complications of, 196.

Typhus, Ijehaviour of body temperature in,
in man and in animalsthatcan be experi-
mentally infected, 455.

blood in, 196.

bnlbo-pontine syndrome in, 195.

cerebrospinal fluid in, 195.

diagnosis of, 197.

epidemiology of, 191.

inculiation period in, 194.

projihylaxis of, 197.

pulmonary congestion in, 195.

relapse in, 194.

serological studies on, 163, 170.

symptomatology of, 194.

treatment of, 198.

without eruption, 194.
Tyrosinase, 230.

Ulcer, duodenal, treatment of, 14.

Ulcei'S, gastric and duodenal, 4.

Ulcus molle, 218.

Ultra-violet rays, use of, in preparation of
vaccines, 356.

Urea, distribution of, in organism, 576.

Urinary acidity, relationsliip between, and
plasma bicarbonate following administra-
tion of sodium bicarbonate, 173.

Urine, estimation of phenolic substances in,
86.
normal human, experiments on source of

variations in reaction of, 385.
normal and pathological, proteoclastic

enzymes in, 385.
secretion, influence of acacia-glucose in-
jections on, 277.

Urochromogen, 282.

Urticaria, 113.

Uterine fibroids, radium therapy for, 285.

Uterus, involution of, following labour, and
influence of castration and sucking on
process of involution, 474.
radiotherapy of carcinoma of, at gynaeco-
logical clinic at Erlangen, 288.
radium treatment of sarcomata of, at
gynaecological clinic at Erlangen, 286.

Vaccination, 205.

complications of, 208.

prophj-Iactic, of 1,536 persons against acute

respiratory diseases, 1919-20, 267.
statistics, 205.
technique of, 207.
Vaccine treatment of dysentery, 404.
treatment of typhus, 199.
treatment of whooping-cough, 203.
Vaccines, use of ultra-violet rays in prepara-
tion of, 356.
Vaccinia, generalized, in Burmese children,

208.
Vagotonia in asthma, 312.
Vagus, irritation of, causing haemorrhagic

erosions of stomach, 5.
Vasomotor reactions, peripheral and pul-
monary, parallelism between, 167.
Vegetables, sun-dried, antiscorbutic and anti-

beri-beri properties of certain, 574.
Veins, functional activity of, 278.

I. INDEX OF SUBJECTS

xvii

Ventriculograpliy, localization or elimination

of cerebral tumours by, 182.
Vertebral artery, 322.
— , aneurysm of, 330.
— , ligation of, 380.
bodies, disappearance of, 372.
column, rare malformation of cephalic end

of, 370.
Vibrio cholerae, serological races of, and relation

to some other vibrios, 455,
Vitamine content of milk, 84.

fat-soluble, critique of experiments with

diets free from, 177.
— , differentiation of yellow plant pigments

from , 84.
— , effects of heat, aeration, and ozone on,

84, 85.
water-soluble B, changes in interstitial

tissue of testicle in consequence of

deficiency in, 168.
— , and secretin, supposed identity of, 468.
Vitamines, antiscorbutic and anti-beri-beri in

certain sun-dried vegetables, 574.
distribution of, 468.
influence of diet of cow upon nutritive and

antiscorbutic properties of cow's milk,

in nutrition of bacteria, 387,
similarity of effects produced by absence of,
and by exposure to X-rays and radium,
466, 487.
Vitiligo, effects of light baths on, 111.
Volatile substances, immediate action of, 477.
Volvulus of sigmoid flexure, surgical treat-
ment of, 227,
Vulva, melanotic cancer of, 234.
Vulvo-vaginitis, gonorrhoeal, in children,
treatment of, 217.

Wassermann reaction in chronic splenome-
galy, 121.
in diagnosis of congenital syphilis, 412.

Wassermann reaction in patients affected with
malaria in tropics, 357.
relation of Sachs-Geoi gi reaction to, 362.
value of, in pregnancy, 409.
value of simultaneous testing for, with two
different antigens and ' ice-box method ',
58.
Water content of human organism, regula-
tion of, 476.
Weil-Felix reaction in tj-phus, 197.
Wertheim's hysterectomy for advanced
carcinoma of cervix made possible by use
of radium, 584.
Whitefish sperm, chemistry of, 89.
Wildbolz's auto-urine test for active tubercu-
losis, 66, 559.
Whooping-cough, 201.
aetiology of. 201.

association of, with influenza, 201.
epidemiology of, 201.
investigations at State Serum Institute in

Copenhagen, 561.
symptomatology of, 201.
treatment of, 202.
Wound diphtheria, 23.
bacteriology of, 162.
Wrist, treatment of acute suppuration of, 236.

X-ray dosage, suggested new method of
measuring, 182.
epitheliomata, treatment of, with radium,

114.
therapy with new apparatus giving 200,000
volts, 287.
X-rays, similarity of effects produced by
vitamines and, 466, 487,
in treatment of oriental sore, 114.
Xylose, fermentation of, by bacteria of
aerogenes, paratyphoid B, and typhoid
groups, 77.

Yeast, nutritive value of, in bread, 468.

II. INDEX OF AUTHOKS

Aaser, E., heart failure in diphtheria, 23.
Aaser, P., non-specific horse serum in tre'at-

ment of diphtheria, 29.
Abderhalden, E., rate of sedimentation of

red cells during pregnancy, 543.
rate of deposition of erythrocytes in plasma

and its relation to protective ferments,

176.
Abelin, J., influence of specific iodine com-
pounds upon metamorphosis of frog's

larvae and of axolotl, 578.
Abrahamsen, A., Kohler's disease, with

special reference to its aetiology, 345.
Abrami, P. : see Widal, P., Abrami, P., et

lancoresco, N.
Adams, F. D., carcinoma of pancreas, 513.
Adams, J., antenatal treatment of syphilis,

413.
Adamson, H. G., treatment of lupus vulgaris

with liquid acid nitrate of mercury, 112.
keratodermia blennorrhagica a form of

psoriasis, 110, 212.
Adler, F. H., carcinoma of pancreas, 513.
Adolph, E. F., regulation of water content of

human organism, 476.
Adrian, C, et Roederer, J., affections of

joints in sclerodermia, 113.
Agar, M., treatment of hay fever, 310.
Agnew, F. F,, haemorrhage following re-
moval of tonsils, 326.
Agulhon et de Leobardy, J., employment in

haematology of complex stains based on

Romanowsky principle, 364.
De Albertis. D., quick process for staining

neuroglia fibres, 168.
Albu, A., congenital predisposition to peptic

ulcer, 5.
prognosis of dysentery, 403.
ulcerative colitis a sequel to bacillary

dysentery, 401.
Alexander, H., Wildbolz's auto-urine reaction

in diagnosis of active tuberculosis, 559.
Alexander, H.L., precipitin response in blood

of rabbits following subarachnoid injec-
tions of horse serum, 569.
Alexander, M. E., and Macdonald, E. L., im-
munity against influenza, 304.
Alexander, W., ligation of vertebral artery,

330.
inquiry into distribution of blood groups

in patients suffering from ' malignant

disease', 461.
Alezais et Peyron, development of so-called

mixed tumours and cylindromata of

facial region, 467.

Alilaire, E., et Fernbach, E., cultivation of
tubercle bacillus in glycerine-free media,
261.

Allen, F. M., dietetic treatment of diabetes,
505.
experimental studies in diabetes. Influ-
ence of cold, 276.
influence of extremes of age, 276.
influence of fever and intoxication, 275.
influence of pregnancy upon experimental
diabetes, 281.

Allen, F. M., Mitchell, J. W., and Sherrill,
J. W., dietetic treatment of diabetes, 506.

Allen, F. M., and Wishart, M. B., exercise in
treatment of diabetes, 504.

Alsberg, J., neosalvarsan in treatment of
pulmonary gangrene, 316.

Amoss, H. L., immunological distinctions of
encephalitis and poliomyelitis, 263.

Amoss, H. L., Gates, F. L., and Olitsky,
P. K., simplified production of anti-
meningococcic serum, 81.

Amsden, H. H., haemorrhage following re-
moval of tonsils, 826.

Anderodias et Dubreuil, G., diabetes and
glycosuria, 501.

Anderson, J. F., improved method for pro-
duction of antimeningococcic and other
serums, 82.

Anderson, R. A., and Schultz, 0. T., immuno-
logic study of strains of Bacillus pfeifferi
isolated from a case of meningitis, 561.

Andre-Thomas, pilomotor reflex. 246.

van Anrep, G., and Drummond, J. C, note
on supposed identity of water-soluble
vitamine B and secretin, 468.

Antoine, E., severe forms of recto-colitis, 12.

Aoki, K., u. lizuka, N., studies on sub-
groups of Proteus. Cross-agglutination
as differential-diagnostic means, 272.

Apert, E., et Cambess6des, predominance of
whooping-cough among f6males, 201.

ApoUoni, G., pancreatic calculi, 514.

Armand-Delille, P. F., intra-muscular route
for injection of diphtheria antitoxin,
28.
prophylaxis of typhus in armies on active
service, 197.

Armand-Delille, P. F., et Marie, P. L., Schick
test for susceptibility to diphtheria, 26.

Aschenbeim, splenic anaemia of infancy, 119.

Ascoli, M., e Fagiuoli, A., treatment of
bronchial asthma by irradiation of
hypophysis, 312.

Asua, F. J., diseases of spleen, 118.

11. INDEX OF AUTHORS

XIX

Aszodi, Z., •hemical heat regulation of mam-
mals. Artificial hibernating state in
mice, 378.

Aub, J. C, Cunningham, T. D.. and Wu, H.,
experimental tiaumatic shock. I. The
basal metabolism. II. Oxygen content
of blood. III. Chemical changes in
blood, 275.

Audrain, J., intramuscular injection of ether
in treatment of whooping-cough, 202.

Audry, C, tumours of scalp containing brain
tissue, 114.

Auguste, C. : see Legrand et Auguste, C.

Avery, O. T., and Cullen, G. E., studies on
enzymes of pneumococcus. I. Proteo-
lytic enzymes. II. Lipolytic enzymes :
esterase. III. Carbohydrate-splitting
enzymes : invertase, amylase, and inu-
lase, 71.

Avery, O. T. : see ThJ0tta, T., and Avery,
6. T.

Azzi, A., parallelism between peripheral and
pulmonary vasomotor reactions, 167.

Bablet. J., bacteriophagic principle of
d'Herelle, 74.

Bach, F. W., comparative studies on races of
Proteus, with special reference to their
capability to produce haemotoxin, 272.

Bacharach, A. L. : see Jcphcott, H., and
Bacharach, A. L.

Bacmeister, A., herpes zoster, infection in,
112.

Bagg, H. J., response of animal organism to
repeated injections of an active deposit
of radium emanation. Intravenous in-
jections in dogs, 185.
see Gudernatsch, J. F., and Bagg, H. J.

Bags, H. J., Ewing, J., and Quick, D., experi-
mental study of eflfects of radium emana-
tion on brains of animals, 585.

Balint, A.: see Hamburger, R., u. Balint, A.

Ballance, C, and Edmunds, W., ligature of
the large arteries in continuity, 329.

Barbour, H. G., and Baretz, L. H., tempera-
ture changes induced by gum acacia injec-
tions in normal and fevered animals,
90.

Barclay, A. E., danger of Coolidge tube for
screen work, 394.

Barcroft, J., anoxaemia. 430.

Bardet : see Dobreuilh et Bardet.

Baretz, L. H.: see Barbour, H. G., and
Baretz, L. H.

Barnes, W. H., activity of staphylococci in
milk, 256.

Ban, D. P.: see Peters, .J. P. (Jr.), and
Barr, D. P.
see Peters, J. P., Barr, D. P., and Rule,
F. D.

Barsony, T., symptoms due to extreme elonga-
tion and dilatation of colon, 14.

Baruch, M., toxic complications following
injections into spinal theca, 521.
see Kiittner, H., u. Baruch, M.

Basch, S., primary sarcoma of stomach, 9.

Bassett-Smith, P. W., influenza epidemics in
the navy, 1918-19, 296.

Bastedo, W. A., surgdrj- in treatment of

peptic ulcer, 14.
Bau, A., determination of oxalic-acid and

nxaluric acid in urine and faeces, 473.
Baudoin, C, suggestion and auto-suggestion,

244.
Baudrimont, A., bilateral hygroma of pre

patellar bursa after influenza, 301.
Baudru, L. : see Nanta, A., et Baudru, L.
Bauer, E. L., Shick test for susceptibility to

diphtheria, 25.
Bayliss, W. M., psychical disturbances due

to oxvgen want, 427.
Bazett, H. C: see Corbett, C. D. II., and

Bazett, H. C.
Becher, 11., oil of turpentine in olive oil in

treatment of septic conditions of skin,

111.
Bechhold, W., structure of red blood cor-
puscles and haemolysis, 367.
Becker, G., complement fixation by hosts of

Bothriocephahis, 163.
Beckmann, K., haemolytie jaundice, 122.
Beckwith, T. D., and Lyon, R. H., viability

and growth of B. typhosus in bile, 79.
B^clere, use of radiotherapy in Basedow's

disease, 390.
Beclfere, A., radium treatment of sarcomata

of uterus at gynaecological clinic at

Erlangen, 286.
radiotherapy of carcinoma of uterus at

gynaecological clinic at Erlangen, 288.
Becl6re, H. : see Duval, P., Roux, et Becl6re, H.
Behmer, W., biology and biochemistry of B.

protens and attempts at the isolation of

pathogenic bacteria from Proteus-con-

taminated material by means of agar

plates contain ing carbolic acid or Eichloif-

blue, 80.
Behrend, M., improved technique for removal

of gall-bladder, 129.
Bell, H. H., relation of different strains of

influenza bacilli as shown by cross-
agglutination and absorption tests, 155.
Bellot, A.: see Degrais, P., et Bellot, A.
Benedetti. U., annular pancreas, 509.
Bennett, T. I., and Dodds, E. C, gastric and

respiratory response to meals, 466.
Bensaude, R., et Vicente, M., bile enemata

in treatment of constipation, 15.
Berge, A., et Hufnagel, L., skin eruptions in

influenza, 300.
Bergeim, O. : see Hawk, P. B., Smith, C. A.,

and Bergeim, 0.
Bergonie, J., heat dermatitis following a

chronic X-ray dermatitis, 391.
Bcrthier : see Olmer, D., et Berthicr.
Bertolotti, M., congenital anomalies of cer-
vical spine, 342.
see Mattirolo, G., e Bertolotti, M.
Bertoye : see Mouriquand, G., et Bertoye.
Besson, A., et de Lavergne, on Morgan's

bacillus, 271.
Bettmann, seasonal variations in skin

diseases. 111.
Beuttner, O., et Chapnis, R., radium therapy

of cancer of cervix, 392.
Bezancon, F., et de Jong, S. I., eosinophiiia

in sputum in asthma, 311.

b :>

n. INDEX OF AUTHORS

Biberfel'i, J., acclimatizaticn to drugs. Ac-
climatization to codein derivatives
(eucodal and paracodein), 180.

Bieber, W., diphtheria prophylaxis, 26.
practical protective value of Behring's
toxin-antitoxin mixture against diph-
theria, 454.

Bier, A., and Others, 45th conference of
German Surgical Society (Surgical Tuber-
culosis), 435.

Biffis, P., familial haemolytic jaundice, 123.

Bigger, J. W. : see Stokes, A., and Bigger,
J. W.

Bihlmeyer, G., rashes in diabetic children,
500.

Binet, L. : see Rathery, F., et Binet, L.

Bingel, non-specific horse serum in treatment
of diphtheria, 28.

Birk, W., non-specific horse serum in treat-
ment of diphtheria, 28.

Birley, J. L., effects of flying at high altitudes,
428.

Bishop, W. A. : see Brosius, 0. T., and Bishop,
W. A.

Bittorf, A., influenza complicated bysymptonis
of Menieres disease, 301,

Blake, F. G. : see Cecil, R. L., and Blake, F. G.

Blake, F. G., and Cecil, R. L., experimental

pneumonia. IX. Production in monkeys

of an acute respiratory disease resembling

influenza by inoculation with Bacillus in-

fliiemae, 152.

Blake, F. G., and Trask, J. D., susceptibility
of monkeys to virus of measles ; their
symptomatology and pathology when
experimentally infected, 354.

Blanc, G., researches on the virus of herpes,
451.

Blanc, J., et Pozerski, E., reaction of bio-
logical media, 564.

Blanc, N. E. : .see Cooper, G. M., Mishulow, L.,
and Blanc, N. E.

Blanchard, development of phagedaena in
vaccine pustule, 208.

Blau, A. I., Shick test for susceptibility to
diphtheria, 25.

Bloch, Br., u. Loffler, W., cause of skin colour
in Addison's disease, 230, 231.

Bloch, C. E., aetioloay of infantile diarrhoea,
12.

Bloomfield, A. L., mechanism of bacillus
carrier state with special reference to
Friedlaender's bacillus, 467.

Bloor, W. R., blood phosphates in lipaemia
produced by acute experimental anaemia
in rabbits, 174.
see Sundstroem, E. S., and Bloor, W. R.

Blumenthal, F., results of treatment of cancer
of breast by excision and radiation,
420.

Blumenthal, G., aetiology of bacillary
dysentery, 272.

Boas, E. P. : see Fishberg, M., and Boas, E. P.

Boas, I,, cause of gastric ulcer, 5,

de Boer, S., fibrillation of heart, 472.

Bogendorfer, L., effect of sweating and diu-
retics on blood and body- weight with diet
rich and poor in salt, 575.

Biihm, A., epidemiology of influenza, 295.

Boidin, L., diphtheria with multiple and
subintrant relapses, 23.

Bolaffi, A., dual histopathological character
of spirochaetosis ictero-haemorrhagica :
relation with acute yellow atrophy of
liver, 374.

Bond, C. J., auto-haemagglutination, 358.

Bonnet, E., et Sicard, J., meaning of term
'emerods' used in Bible, 399.

Bonnet, L. M , et Morenas, large doses of
cacodylate of soda in treatment of lichen,
111.

Borchardt, L., u. Ladwig, B , intramuscular
injections of milk in influenza, 305.

Bordet, F.: see Ratherj', F., et Bordet, F.

Bordet, J., theories of blood coagulation, 550.

Bordet, J., et Ciuca, M,, leucocytic exudates
and transmissible bacterial autolysin, 62.
production and interpretation of d'Herelle's
bacteriophage, 62.

Borelli, E., superficial inguinal hernia, 241.

Boring, E. G., results of experimental nerve
section in man, 46.

Bornstein, A., adrenalin glycaemia, 576.

Bornstein : see Sanger u. Boi-nstein.

Bory, M. L., aetiology of psoriasis, 110.

Boss, W., results of treatment of cancer of
breast by excision and radiation, 423.

Boughton, T. H. , anaphylactic deaths in
asthmatics, 311.

Bourges, H., haemolytic jaundice caused by
Ascaris lumbricoides, 105.

Bourn, J. M. : see Stillman, E. G., and Bourn,
J. M.

Bradford, J. R., obs<3ure disease of spleen, 121.

Bradley. H. C, and Felsher, H., studies of
autolysis. VI. Effect of certain colloids
upon autolysis, 86.

Branham, S. E.. and Hall, I. C, attempts to
cultivate filtrable viruses from cases of
influenza and common colds, 264.

Brattstrom, E., results of treatment of cancer
of breast by excision and radiation, 423.

Du Bray, E. S., gastric polyposis, 9.

Du Bray, E. S., and Rosson, F. B., new
growths of pleura, 319.

Breinl, F., paragglutination, 355.

Brewster, G. W. W., right colectomy, 224.

Bridge, N., pulmonary streptothricosis, 317.

Briggs, H., physical exertion, fitness, and
breathing, 280.

Brigham, F. G,, mortality from diabetes, 498 ;
obesity and diabetes, 503,

Brooks, M. M., effectsof bile salts and saponin
on respiration, 383.

Brosius, O. T., and Bishop, W. A., ankylo-
stomiasis in natives of Zaragosa, 107.

Brown, E. J., local anaesthesia by quinine
salts, 520.

Brown, W., psychology and psychotherapy,
245.

Brown, W. H., and Pearce, L., superinfection
in experimental syphilis following the
administration of subcurative doses of
arsphenamine or neoarsphenamine, 570.

Browning, C. H., and Gulbransen, R., anti-
septic potency of acriflavine, with con-
siderations on variability of results in
testing antiseptics, 465.

II. INDEX OF AUTHORS

XXI

Browning, C, H., and Wilson, G. H. . anti-
genic properties of globin, with a note
on the independence of properties of
serum and tissue proteins as exemplified
by absence of antibody from globin of an
immunized animal, 165.

Brownlie, J. L., vaccine treatment of diph-
theria, 30.

Brun, R., origin and symptomatology of
lumbago, 349.

Briining, H., gastric analysis in children, .3.

Brunn, F., Hitzenberger, K., u. SaxI, P.,
periodicity of gastric ulcer, G.

Bruusgaard, E.j neurosyphilis, 00.

Bumke, O., troubles due to lumbar puncture,
520.

Bunting, C. H., and Huston, J., fate of the
lymphocyte, 572.

Burns, A., relation of tonsil to adjacent
arteries, 325.

Burridge, W., researches on perfused heart,
280.

Burrows, A., report of Manchester and Dis-
tiict Radium Institute, 283.
see Shaw, W. F., and Burrows, A.

Busacca, A., growth-curve of human spinal
ganglion-cell, 371.

Bussy, L. : see Japiot, P., et Bussy, L.

Butler, E. F., hypertrophic pulmonary osteo-
arthropathy following lung abscess, 315.

Buttenwieser, S., haemorrhagic encephalitis
as complication of dysentery, 402.

Byrne, J., paradoxical pupil dilatation follow-
ing lesions of afferent paths, 550.

Caius, J. F., and Mhaskar, K. S., chemical
composition and therapeutic value of
anthelmintics, 106.

Caldarola, P., serological investigations on
meningococci, parameningococci, and
gonococci, 450.

Calderone, A., experimental investigation on
phagocytosis. Influence of diluted
.solutions of hydrochloric acid, 171.

Calv6, J., non-tuberculous juvenile coxalgia,

OJT,

Cambess^des: see Apert, E., et Cambessed6s.

Cameron, A. T., and Carmichael, J., bio-
chemistry of iodine. III. comparative
effects of thyroid and iodide feeding on
growth in white rats and in rabbits,
179.

Campo, G., modern methods of diagnosis of
cancer of stomach, 92.

Cantacuz6ne, J., Roumanian epidemic of
typhus in 1917-18, 191, 195.

Canuyt, G., ulceration of larynx after in-
fluenza, 301.

Capelle, anaesthesia of brachial plexus, 525.

Capone, G., studies on anaerobic flora of some
morbid states of intestine, 159.

Carini, A., bronchial spirochaetosis, 313.

Carisi, G., primary sarcoma of lung, 318.

Carmichael, J. : see Cameron, A. T., and
Carmichael, J.

Camot, P., plastic linitis, 4.

Cartesegna, M., e Casassa, A., diphtheria
bacilli in urine of cases, 19.

Carulla, J. E. : see Udaondo, C. B., y Carulla

J. E.
Casassa, A. : see Cartesegna, M., e Casassa, A.
Cassirer, R.. u. Lewy, F. H., two cases of

superficial brain tumour, 446.
Castigliola, O., treatment of amoebic abscess

of liver, 404.
Castronuovo, O., infectious diseases and

diabetes, 497.
Cathala, J. : see Lian, C, et Cathala, J.
Catsaras, J., fatty embolism in lungs in cases

dying of influenza, 298.
Cattoretti, F., haematological and serological

investigations on typhoid fever patients

treated with heterologous (anticholora)

vaccine, 356.
Cauchoix, A., pulsating exophthalmos treated

by ligature of both common carotids, 426.
Cazeneuve, H. J., blood in typhus, 196.
Cecil, R. L. : see Blake, F. G., and Cecil, R. L.
Cecil, R. L., and Blake, F. G., studies on

experimental pneumonia. X. Pathology

of experimental influenza and of Bacillus

injluemae pneumonia in monkeys, 153.
Cecil, R. L., and Steffen, G. I., acute

respiratory infection in man following

inoculation with virulent B. injluemae,

264.
Celsus, old methods of removal of tonsils, 326.
Cernezzi, A., treatment of large umbilical

and ventral hernias, 239.
Chapuis, R. : see Beuttner, O., et Chapuis, R.
Chaput, treatment of acute suppuration of

wrist, 236.
Chartier, treatment of medullary and radical

after-effects of epidemic encephalomye-
litis, 493.
Chatellier, L., erythromelalgia cured by single

injection of adrenalin, 113.
Chaton et Sauve, grafts of dead tendon, 529.
Chauffard, immunity against influenza, 304.
Chauveau, A., absence of internal carotids in

sheep, 323.
Cheinisse, treatment of chancroid, 219.
Cheinisse, L., intramuscular injection of

ether in treatment of whooping-cough,

202.
prophylaxis of influenza, 305.
Cheplin, H. A., and Rettger, L. F., intestinal

implantation of Bacillus acidophilus, 90, 178.
Chesney, A. M. : see Rowntree, L., Chesney,

A. M., and Marshall E. K.
Chevrotier, J. : see Lumiere, A., et Chevro-

tier, J.
Chicandard, M., tuberculosis of calcaneus in

children, 482.
Chievitz, 0., Jenson, J., Reyn, A., and Collin,

E., surgical treatment of osseous and

articular tuberculosis, 438.
Chiray, M., excretion of glycuronates in cases

of vomiting of pregnancy, 541.
Chotzen,T. : see SchaeSer, F., and Chotzen, T.
Christiansen, M., gas phlegmon following

subcutaneous injections, 568.
Christensen, S. : see Thomsen, 0., and

Christensen, S.
Churchman, J. W., cause of parallelism

between Gram reaction and gentian

violet reiction. Isolation of gentian-

xxu

II. INDEX OF AUTHORS

positive individuals from a suspension
of a gentian-negative organism. Relation
of gentian violet reaction to dilution of
implanted suspension. Effect of repeated
re-inoculations of gentian violet agar with
gentian-positive organisms. Selective
action of gentian violet in relation to
chemotherapy. Communal activity of
bacteria, 91.

Ciani, 6., cultures of anaerobic germs in
ordinary Petri dishes in presence of air,
354.

Ciccarelli, F., transient polyomyelitis after
influenzal broncho-pneumonia, 299.

Oiuca, M. : see Bordet, J., et Ciuca, M.

Civatte, A., et Vigne, P., treatment of sarcoid
of Boeck-Darier by intravenous injection
of salvarsan, 114.

Clement, R. : see Ramond, F., et Clement, R.

Clemow, F. G., typhus in Turkey, 193.

Clendening, L., pulmonary abscess, 315.

Cluzet, Rochaix.et Kofman, bactericidal action
of radium on B. pyocyaneus, 187.

Coca, A. F., and Kelley, M. F., serological
study of bacillus of Pfeiffer, 267.

Cockcroft, W. L., Loewi's adrenalin test for
pancreatic insufficiency, 514.

Cohen, C, on formation of acetaldehyde
during decomposition of sugar by moulds,
388.

Cohen, M., and Levin, I., action of radium in
cataract, 285.

Cole, L. G., and Roberts, D., duodenal di-
verticula : their clinical and radiological
aspect, 183.

CoUignon : see Monziols et CoUignon.

Collin, E. : see Chievitz, 0., Jensen, J., Reyn,
A., and Collin, E.

Collip, J. B., eflect of surgical anaesthesia on
reaction of blood, 67.

Connell, A. A., Cyst of common bile-duct,
128.

Conseil, E. : see NicoUe, C, et Conseil, E.'

Constantinesco, C. D., et Sloboziano, typhus
without eruption, 194.

Cooke, J. v., complement fixation in influenza
with B. influenzae antigens, 155.

Cooper, G. : see Park, W. H., and Cooper, G.

Cooper, G. M., Mishulow, L., and Blanc, N. E.,
study of the serological relationships of
pneumococci from the upper respiratory
tract, with special reference to common
colds and influenzal conditions, 267.

Corbett, C. D. H., and Bazett, H. C, cerebral
effects of oxygen want, 431.

Corinaldesi, S., jaundice in influenza, 299.

Corper, H. J. : see Hektoen, L., and Corper,
H. J.

Corper, H. J., and Rensch, O. B., effect of
mustard gas on experimental tuberculosis,
369.

La Coste et Ferrier, injury causing spasmodic
contraction of arteries, 33.

Costiniu, A., aural and laryngeal complica-
tions of typhus, 196.

Cottin, E., Cramer, A., et Saloz, C, cancer of
lung, 317.

Couillaud, F., tongue sign in helminthiasis,
103.

Coulet, G., fatal tonsillar abscess after in-
fluenza, 301.

Coulter, C. B., equilibi'ium between haemo-
lytic sensitizer and red blood cells in
relation to hydrogen-ion concentration,
378.
isoelectric point of red blood cells and its
relation to agglutination, 176.

Courcoux: seeLegry, Courcoux,et Lermoyez, J.

Coutela, C, retinitis in diabetics, 500.

Cowan, M. L. : «ee Haitian d, H. B., Cowan,
M. L., and Detweiler, H. K.

Coward, K. II. : see Drummond, J. C, and
Coward, K. H.
se« Drummond, J. C.,Golding,J., Zilva,S. S.,
and Coward, K. H.

Cramer, A. : see Cottin, E., Cramer, A., et
Saloz, C.

Ci'amer, W., and Mottram, J. C, similarity
of effects produced by absence of vitamines
and by exposure to X-rays and radium,
466, 487.

Cranston Low, R., Logan, W. R., and Ruther-
ford, A., fatal case of lupus erythematosus,
112.

Cristol et Porte, gas cysts of abdomen, 11.

Crohn, B. B., and Reiss, J., effects of restricted
(so-called ulcer) diets upon gastric secre-
tion and motility, 15.

Cron, R. S., glycosuria and pregnancy, 501.

Croutei-, C. Y. : see Hendrix, B. M., and
Crouter, C. Y.

Crowell, B. C, distribution and effects of
Ascaris lumbricoides, 104.

Cu^nod, A. : see Nicolle, C, et Cuenod, A.

Cullen, G. E. : seeAvery,O.T., and Cullen,G.E.

CuUis, W. C, and Hewer, E. E., 'ammonia
coefificient ' of pregnancy, 89, 538.

Culver, G. D. : see Montgomery, D. W., and
Culver, G. D.

Cunningham, T. D. : see Aub, J. C, Cunning-
ham, T. D., and Wu, H.

Curatolo, F., sodium lactate in treatment of
diabetes, 506.

Curschmann, H., defects of endocrine glands
in causation of bronchial asthma, 310.

Gushing, H., and Foley, F. E. B., alteration
of intracranial tension by salt solution in
alimentary canal, 178.

Cutler, E. C, abscess of spleen following otitis
media, 119.

Dahle, C. H. : see Dutiker, R. A., Eckles, C. H.,
Dahle, C. H., Mead, S. W., and Schaefer,
O. G.

Daken, J., treatment of gonorrhoeal vulvo-
vaginitis in children, 217.

Dandy, W. E., diagnosis and treatment of
hydrocephalus due to occlusion of fora-
mina of Magendie and Luschka, 549.
localization or elimination of cerebral
tumours by ventriculography, 182.

Daniels, A. L., and Loughlin, R., deficiency
of heat-treated milks, 85.

Danis, M., inflammation of cellular tissue of
right orbit following influenzal pneu-
monia, 301.

Darier, J., myiasis c\ued by excision, 114.

II. INDEX OF AUTHORS

XXlll

Darier, J., pitcancerous deruiatosis, 114.
Darier, J., et Hall6, J., naevus derived from

bronchial clefts, 114.
Darling, S. T., mass treatment of hookworm

infection, 107.
Daubit, polysulpliide of calcium in treatment

of scabies, 113.
Davey, A^ J., dutermination of minimum

doses of some fresh citrus fruit juices

which will protect a guinea-pig from

scurvy, together with f-ome observations

on preservation of such juices, 386.
Davide, H. L., aetiology of influenza, 563.
Davis, L. C. : ?ee Kolmer, J. A., Davis, L. C,

and Jager, R.
Davis, L. H. : see Ross, E. L., and Davis, L. H.,

274.
Davis, L. H., and Ellison, L. R., source of

diastases in blood, 469.
Davis, T. K. : see Kirby, G. H., and Davis, T. K.
Davison, W., divisions of so-called Flexner

group of dysentery bacilli, 77.
Davison, W. C, ileo-colitis in children in

Maryland and Alabama due to B. dys-

enteriae, 400.
Dawson, P. R. : see Sullivan, M., and Dawson,

P. R.
Deaver, H. C, cholecystitis following typhoid,

127.
Deaver, J. B., McFarland, J., and Herman,

J. L., statistics relating to treatment of

cancer of breast by excision and radiation,

419.
Debre, R., et Haguonau, some peculiarities of

' d'Herelle phenomenon ', 74.
Degrais, P., et Bellot, A., treatment of X-ray

epitheliomata with radium, 114.
Deibert, O. : see Teague, O., and Deibert, 0.
Delherm et Laquerri6re, electro-radiology in

neuritis of motor nerves, 492.
Delmas, P., general analgesia by cocaine

injected into spinal theca, 522.
Denk, W., general and local anaesthesia, 516.

intestinal exclusion, 137.
Denny, H. T. : see Povitsky, 0. R., and Denny,

H. T.
Dercum, F. X., intraspinal treatment of

neurosyphilis with salvarsanized serum,

338.
Desderi, P.: see Volpino, G., e Desderi, P.
Dessane ; see Gougerot et Dessane.
Detweiler, H. K. : see Maitland, H. B.,

Cowan, M. L., and Detweiler, H. K.
Deuel, jun., H. J. : see Holmes, A. D., and

Deuel, jun., H. J.
Dible, J. H., enterococcus and faecal strepto-
cocci : their properties and relations, 257.
Dickson, W. E. C. , congenital obliteration of

bile-ducts, 127.
Dide et Guiraud, special staining method for

lipoid granules in nerve-cells, 252.
Dienst, A., eclampsia due to thrombus forma-
tion, 543.
Diez, S., trauma and diabetes, 497.
Di Macco, G., on influence of nutrose in

culture medium of Drigalski-Conradi, 77.
experimental investigations on phago-
cytosis. Influence of fatigue, 171.
see Mubumeci, G., e Di Macco, G.

Dind, M., lichen and lichenification, HI.
Dixon, W. E., and Ransom, F., immediate

action of volatile substances, 477.
Dobreuilli et Bardet, deformities of hands
since childhood caused by cicatrices, 482.
Dodds, E.G. : see Bennett, T. I., and Dodds,

E. C.
Doerr, R., oligodynamic action of silver, 480.
Doerr, R., Schnabel, A., u. VOchting, K.,
behaviour of body temperature in typhus
in man and in animals that can be
experimentally infected, 455.
Dold, H., und Fischer, W., a case of naturally
acquired bacillary dysentery in dog with
simultaneous schistosomiasis, ankylosto-
miasis, and filariasis, 79.
Dopter, C., immunity against influenza, 303.
Doran, A. , melanotic cancer of vulva secondary

to adrenal tumour of kidney, 234.
Dorland, N., methylene blue in treatment of

gonorrhoea in women, 216.
Douglas, S. R., question of serological races
of V. cholerae and relation of some other
vibrios to this species, 455.
Downey, H. : see Mandlebaum, P. S., and

Downey, H.
Dragstedt, L. R. , effect of Streptococcus haemo-
lyticus infection on reaction of blood of
rabbits, 69.
Draper, G., acute poliomyelitis, 146.
Dreyer, G., simple procedure for accurate
enumeration of blood-cells and bacteria
without the use of a counting chamber,
364.
Dreyfus, G. L., constitution of cerebrospinal
fluid — deciding factor for prognosis and
therapy in syphilis of nervous system,
59, 336.
Drummond, J. C, nutrition on diets
practically devoid of fat, 178.
see van Anrep, G., and Drummond, J. C.
Drummond, J. C, and Coward, K. H.,
researches on fat-soluble accessory factor
(Vitamine A.) VI. Effect of heat and
oxygen on nutritive value of butter, 84.
Drummond, J. C, Golding, J., Zilva, S. S.,
and Coward, K. H., nutritive value of
lard, 85.
Driiner, hemiplegia following ligature of

common carotid, 324, 328.

Dubourg et Guenard, F., mortality from

diphtheria in children's hospital in

Bordeaux from 1888 to 1917, 18.

Dubreuil, G. : see Anderodias et Dubreuil, G.

Dubreuilh, W., infective pruriginous eruption

among Tonkinese and Annamites, 113.
Ducceschi, V., influence of ethyl alcohol on

organism, 463.
Duchemin, B., sarcoma of spleen, 120.
Dudgeon, L. S., blackwater-fever, 457.
Dufour, H., Semelaigne, G., et Ravina, A.,
pulmonary gangrene cured by anti-
gangrene serum, 316.
Dufourt, A. : see Weill, E., et Dufourt, A.
Dumas, J., on presence of bacteriophage in
healthy intestine, in soil, and in water,
74.
Dumitresco-Mante, three forms of pulmonary
congestion in typhus, 195.

XXIV

II. INDEX OF AUTHORS

Duncan, A. G. B. : see Fraser, A. R., and
Duncan, A. G. B.

Dunham, J. H., visceral syphilis mistaken
for duodenal ulcer, 6.

Dup6rie, R,, treatment of congenital syphilis
with subcutaneous injections of novar-
senobenzol and novocains, 416.

Dupuy, test of sham feeding, 4.

Durand, M., grafts of dead tendon, 528.

Duroeux, L. : seeLevy-Bing, A., etDuroeux, L.

Dutiker, R. A., Eckles, C. H., Dahle, C. H.,
Mead, S. W., and Schaefer, O. G.,
Vitamine studies. VI. Influence of diet
of the cow upon nutritive and anti-
scorbutic properties of cow's milk, 177.

Duval, P., Roux, et Bt^clfere, H., ulcer of
smaller curvature of stomach, 182.

Dwyer, H. L., malignant endocarditis due to
GojiococcMS, 211.

van Dyke, H. B., study of distribution of
iodine between cells and colloid in
thyroid gland. III. Effect of stimulation
of vagosympathetic nerve on distribution
and concentration of iodine in dog's
thyroid gland, 475.

Ebaugh, F. G., and Stevenson, G. S., measure-
ment of intracranial pressure changes in
an epileptic, and its experimental varia-
tion, 536.
Eberle, D., invasion of pancreas byascarides,

104.
Ebj', H. : see Howell, K. M., and Eby, H.
Eckles, C. H.: see Dutiker, R. A., Eckles,
C. H., Dahle, C. H., Mead, C. W., and
Schaefer, 0. G.
Edmunds, W. ; see Ballance, C, and Ed-
munds, W.
Ege, R., distribution of glucose between
plasma and red blood corpuscles. Physio-
logy of blood sugar, 377, 471.
Einhorn, M., duodenal perforation treated
by duodenal alimentation, 15.
string test in diagnosis of peptic ulcers, 6.
treatment of impermeable cardiospasm, 15.
Eiskamp, E. H., and Park, L. K., fate of
micro-organisms introduced into isolated
loops of intestine, 79.
Eitner, E., electrolysis treatment of hyper-
trichosis, 114.
EUermann, V., new strain of transmissible

leukaemia in fowls (strain H), 572.
Ellis, N. R. : see Hart, E. B., Steenbock, H.,

and Ellis, N. R.
Ellison, L. R. : see Davis, L. H., and Ellison,

L. R.
Emge, L. A., acidosis in pregnancy, 537.
Engelbreth, C, influenza transmitted through

fleas, 296.
Erlanger, J., blood-pressure estimation by in-
direct methods. Movements in artery
under compression during blood-pressure
determinations, 378.
see W^hite, H. L., and Erlanger, J., 273.
Ernst, N, P., actinotherapy of surgical tuber-
culosis, 437.
Epstein, J. W., intraperitoneal administra-
tion of sodium bicarbonate solution, 480.

Evans, C. L., cyanide anoxaemia, 429.

on probable error in determinations by
means of hydrogen electrode, 255.

Ewing, J. : see Bagg, H. J., Ewing, J., and
Quick, D.

Ewing, J., and Wolf, C. G. L., ammonia co-
efficient in eclampsia, 339.

Eyster, J. A. E. : see Meek, W. J.,andEyster,
J. A. E.

Fagiuoli, A. : see Ascoli, M., e Fagiuoli, A.
Fahr, renal lesions in eclampsia, 540.
Failla, G., radium technique at Memorial

Hospital, New York, 290,
Fairbank, H. A. T,, pseudo-coxalgia — osteo-
chondritis deformans juvenilis, 39.
Falcioni, D., immunity against influenza,

304.
Falta, W., u, Richter-Quittner, M., chemical

composition of blood-corpuscles, 579.
Farah, N., bronchial spirochaetosis, 313.
Farnell, F. J., and Harrington, A. H., acute
infectious enteritis with a polyneuritic
syndrome, 12.
Favrat : see Maisonneuve et Favrat.
Feigl, J., appearance and distribution of fats
and lipoids in blood after bleeding.
Chemical contribution to knowledge of
lipaemia, 376.
composition of liver in acute yellow atrophy,
479.
Felsher, H. : see Bradley, H. C, and Felsher,

H.
Fenn, W. 0., phagocytosis of solid particles.

I. Quartz. II. Carbon, 478.
Fernbach, E. : see Alilaire, E., et Fernbach,

E.
Ferrier : see La Coste et Ferrier.
Feucht, B., Biirker's method for blood counts,

277.
Feulgen, R, : tee Stepp, W., and Feulgen, R.
Ficai, G., serological studies on typhus, 163.
Field, C. G., non-tuberculous lung infection,

313.
Fildes, P., nature of effect of blood-pigment

upon growth of 5. injluensae, 158.
Le Filliatre, G., general analgesia by cocaine

injected into spinal theca, 522.
Findlay, L., treatment of congenital syphilis,

414.
Fineman, B. C, study of thrush parasite,

262.
Finks, A. J. : see Johns, C. O,, and Finks,

A. J.
Finochietto, R. : see Vaccarezza, R. F., y

Finochietto, R.
Finsterer, H., ascites in connexion with duo-
denal ulcer, 5.
general and local anaesthesia, 516.
intestinal exclusion, 138.
Fiolle, J., injury causing spasmodic contrac-
tion of arteries, 33, 35.
Fischer, A. W., death from injection of

suprarenin solution, 518.
Fischer, W. : see Dold, H , u. Fischer, W.
Fishberg, M., and Boas, E. P., outbreak of
influenza in tuberculosis pavilion of
Montefiore Hospital, New York, 301.

11. INDEX OF AUTHORS

XXV

Fisher, A. G. T., absence of internal carotids

in a man, 323.
Fitz, R., diabetes and leukaemia, 501.

surgical complications of diabetes, 500.
Fletcher, H. M., change of type in congenital

syphilis, 410.
Flu, P. C. , period during wliich stegomyia

can live at low temperatures, 477.
Foges, A., treatment of rectal lesions follow-
ing dysentery with quartz lamp, 404.
Foldes, E., u. Hajos, K., treatment of in-
fluenza by subcutaneous injections of
normal horse serum, 305.
Foley, F., fall in cerebrospinal fluid pressure
produced by injections of hypertonic salt
solutions, 536.
Foley, F. E. B. : see Gushing, H., and Foley,

F. E. B.
Foley, F. E, B., and Putnam, T. J., experi-
mental production of alterations in
cerebrospinal fluid pressure and brain
volume, 535.
Folin, 0., level of blood area in normal

pregnancy, 539.
Fontaine, J., measurement of arterial blood-
pressure in horses, 279.
Fontana, A., e Sangiorgi, G., on spironemata

of pointed condylomata, 158.
Foot, N. C, endothelial reactions in tuber-
culosis, 375.
Forbes, A., and Rappleye, W. C, rhythm of

human electromyogram, 531.
Fordyce, J. A., and Rosen, I., intramuscular
injections of neosalvarsan and an oily
suspension of mercury in treatment of
congenital syphilis, 414.
Forestier, J. : see Loeper, M., Forestier, J., et

Tonnet, J.
Forestier, J., et Michon, L., pyelography in
diagnosis of hydatid cysts of kidney, 287.
Fiirssell, G., radiological diagnosis of tuber-
culosis in bones and joints, 481.
Foster, L. F., relation of hydrogen-ion con-
centration to growth, viability, and fer-
mentative activity of Streptococcus haemo-
lijticics, 565.
biochemistry of Streptococcus haetnolyticus,
565.
Foster, L. F., and Randall, S. B., study of
variations in hydrogen-ion concentration
of broth media, 566.
Franz, L., chemotherapeutic experiments
with a view to treatment of diplitheria
of wounds, 355.
Fraser, A. R., and Duncan, A. G. B., vaccine

treatment of diphtheria, 30.
Frassi, L., injury causing spasmodic contrac-
tion of arteries, 37.
Fred, E. B., and Peterson, W. H., fermenta-
tion of xylose by bacteria of aerogenes,
paratyphoid B, and typhoid groups, 77.
Freeman, R. G., vaccine treatment of whoop-
ing-cough, 203.
Freudenberg, E., u. Gyorgy, P., calcium

combination with animal tissues, 478.
Freund, J. : see Rothfeld, J., Freund, J., u.

Hornowski, J.
V. Frey, M., contraction of muscle treated
with veratrin, 532.

Frieberg, F., actinotherapy in three cases of
tumour of hypophysis, 486.

Friedenwald, J., and Grove, G. H., blood-
sugar tolerance in gastro-intestinal carci-
noma, 8.

Friedmann, J. C, non-specific intestinal in-
fection, 12.

Fries, J. A., respiratory quotient and its un-
certainty, 383.

Fritzsclie, R., primary paroncliymatous
haemorrhage from stnmacb, 11.

Frohlich, A., u. Meyer, H., electromyogram
in tetanus, 533.

Frouin, A., fat content of tubercle bacilli of
human, bovine, and avian types respec-
tively, 559.

Friihwald, R., spirochaetes in lymphatic
glands, 58.

Fukuda, A., experiments on anthrax in rats,
161.

Fiirbringer, prevalence of Oxijuris vermicuUiris
caused by war, 105.

Furno, A., chronic lung disease following
influenza, 297.

Fiirth, on antigenic action of attenuated
tubercle bacilli, tortoise and other acid-
fast bacilli, 261.

Fiirth, 0., u. Lieben, F., colorimetric experi-
ments on tryptophane. IV. Formation
of melanoidin in acid hydrolysis of pro-
teins and its dependence upon trypto-
phane complexes. V. Our knowledge of
proteins of immune sera and their trypto-
phane content, 579.

Futcher, T. B., carcinoma of pancreas, 512.

Gad Andresen, K. L., distribution of urea in
organism, 576,

Galambos, A., renal glycosuria, 503.

Galdi, F., pulmonary aspergillosis, 317.

Galewsky, E., eczema caused by leather sub-
stitute in hat linings, 111.
' staphar ' in treatment of chronic sepsis of
skin, 111.

Gallerand : see Ravaut, P., et Gallerand.

Gamma, G., special microscopic finding in
nervous tissue from cases of lethargic
encephalitis, 452.

Gammeltoft, S. A. : see Hasselbach, K. A., u.
Gammeltoft, S. A.

Gane, T., relapse in typhus, 194.

Gardner, E. L. : see Henrici, A. T., and
Gardner, E. L.

Garrod, A. E., diagnosis of disease of pan-
creas, 514.

Gates, F. L. : see Amoss, H. L., Gates, F. L.,
and Olitsky, P. K.

Gates, F. L. : see Olitsky, P. K., and Gates,
F. L.

Gates, F. L., and Olitsky, P. K., factors
influencing anaerobiosis, with special
reference to use of fresh tissues, 454.

Gay, D. M. : see Putnam, J. J., and Gay,
D. M.

Gay, F.P., and Morrison, L. F., experimental
streptococcus empyema. II. Attempts
at dye therapy, 69.

XXVI

II. INDEX OF AUTHORS

Gentili, A., secretory activity of anterior
lobe of pituitary body during pregnancy,
371.

Genoese, G., cerebrospinal fluid in whooping-
cough, 202.

Gerber, I. : see Turretini, G., et Gerber, I.

De Gery, C. P., gas cysts of abdomen, 10.

Gessner, W., Baden statistics of eclampsia
during the war, 543.

Giese, G. : see Kossel, A. , u. Giese, G.

Giffin, H. Z., persistent eosinophilia with
hyperleucocytosis and splenomegaly, 122.
tuberculosis of spleen, 120.

Gilliatt, W., and Kennaway, E. L., ammonia
coeificient in cases of pernicious vomit-
ing in pregnancy, 538.

GiosefS, M., skin eruptions in influenza, 300.

Giuliani, R., sexual neutralization obtained
by means of orchilytic and ovariolytio
sei'a, 169.

Glaessner, K., gastric and pancreatic secre-
tions in bacillary dysentery, 401.

Glass, E., mixed-celled sarcoma of lung, 318.

Glatard, epidemic of typhus in Algeria, 197.
treatment of typhus by intravenous injec-
tions of urotropin, 198.

Gleyvod, P., intramuscular injection of ether
in treatment of whooping-cough, 202.

Golay, M. J., Fontan's method of treating
chancroidal buboes, 220.

Goldberg, B., influenzal haematuria, 299.

Goldberg, J. M. : see Strickler, A., and Gold-
berg, J. M.

Goldberger, I. H., use of inner and back
sides of arm for vaccination, 207.

Golding, J. : see Drummond, J. C, Golding,
J., Zilva, S. S., and Coward, K. H.

Goldman, A. : see Grant, S. B., and Goldman,
A.
see Williams, A. W., Unneberg, A., Gold-
man, A., and Hussey, H.

Goodall, E. W., typhus in Poland, 1916-19,
191.

Goodall, J. R., vaccination by subcutaneous
injection, 207.

Goppert, F., umbilical diphtheria, 22.

Gougerot, complications of vaccination, 208.

Gougerot et Dessane, treatment of warty
naevus in heredo-syphilitic subject, 410.

Gourbis, atonic syndrome of digestive tract
in nervous persons, 389.

Gracey, G. F., hemiplegia following tonsil-
lectomy, 327.

Graham, G., dysenteric arthritis at Malta,
401.

Graham, S. G. : see Imrie, C. G., and Graham,
S. G.

Graham Brown, T., scratch reflex in guinea-
pigs, 429.

Gram, H. C., volume of red blood corpuscles
and ratio of this volume to haemoglobin
and to number of cells, 365.

Gramen, K., Wildbolz's auto-urine test for
active tuberculosis, 66.

Grant, S. B., and Goldman, A., tetany pro-
duced by forced respiration, 432.

Gray, G. A., and Meyer, B. I., diphtheria
carriers and their treatment with mer-
curochrome, 454,

GriflSths, G. H. St. Geo., disadvantages of

novocaine as local anaesthetic, 520.
GroebeljW. : seeTrendelenburg,P.,u. Groebel,

W.
Groedel, F. M., radiological appearances of

encapsuled pleural effusions, 581.
Gronberg, J., blood ferment in pregnancy,

carcinoma, and pulmonary tuberculosis,

162.
Gross, A. : see Korbsch, R., u. Gross, A.
Gross, 0,, forms of pancreatitis, 510.
Grossfeld, H., onychodystrophy following

typhus, 195.
Groth, A., results of vaccination in Bavaria.

205.
Grothusen, dysenteriform catarrh of large

intestine due to flagellata, 399.
Grove, G. H. : see Friedenwald, J., and

Grove, G. H.
Gudernatsch, J. F., and Bagg, H. J., distur-
bances in development of mammalian

embryos caused by radium emanation,

90.
Guenard, F, : see Dubourg et Guenard, F.
Guillain, G., epileptic convulsions inpatient

with diabetes and acetonuria, 499.
Guimbellot, surgical treatment of volvulus of

sigmoid flexure, 227.
Guirard : see Dide et Guirard.
Guisez, J., treatment of cancer of oesophagus

and of larynx by local applications of

radium, 285.
Gulbransea, R. : see Browning, C. H., and

Gulbransen, R.
Gunn, J. A., and Heathcote, R. St. A., cellu-
lar immunity : observations on natural

and acquired immunity to cobra venom,

360.
Gurley, C. R. : see Williams, A. W., Nevin,

M., Gurley, C. R.
Gyorgy, P., sedimentation of blood corpuscles,

377.
see Freudenberg, E., Gyorgy, P.

Habermann, R., u. Mauelshagen, F., value of
gland puncture in early diagnosis of
syphilis, 59.

Halfner, R., relation of placental infarcts and
albuminuria, 544.

Haggard, H. W., anaesthetic and convulsant
effects of gasoline vapour, 280.

Haggard, H. W., and Henderson, Y., haemato-
respiratory functions. IX. An irrever-
sible alteration of HjCOj/NaHCOa equi-
librium of blood induced by temporary
exposure to a low tension of COj, 174.

Haggard, W. D., primary sarcoma of
stomach, 9.

Haguenau: see Debre, R., et Haguenau.

Hahn, M., u. Skramlik, E., expex'iments with
antigens and antilaodies upon surviving
artificially perfused liver. Tetanus
toxin, 388.

Hajos, K. : see Foldes, E., u. Hajos, K.

Haldane, J. S., Kellas, A. M., and Kennaway,
E. L., efiects of oxygen want, 431.

Haldane, J. S., and Poulton, E. P., effects of
oxygen want, 431.

11. INDEX OF AUTHORS

XXVll

J., and

Hall, I. C, chemical criteria of anaerobiosis
with special reference to methylene blue,
453.
see Branham, S. E., and Hall, I. C.
Hall6, J. : see Darier, J., et Halle, J.
d'Halluiu, M., electric currents which kill.
The mode of death. How life may be
saved, 587.
Hamburger, K., u. Balint, A., influenza in

children, 303.
Hamburger, W. W., post-influenzal myocar-
dial involvement, 298.
Hammett, F. S., studies of the thyroid appa-
ratus. I. -Stal»ility of nervous system as
factor in resistance of albino rat to loss of
parathyroid secretion, 475.
Handley, S., tre.itment of cancer of breast by

excision combined with radiation, 419.
Hanganut, M., intravenous injections of re-

sorcin in treatment of influenza, 305.
Hansen, 0. S., magnesium sulphate in arsenic

poisoning, 282.
Harbitz, F., encephalitis neonatorum, 253.
Hari, P., light absorption of reduced haemo-
globin, 376.
Harman, B. , blindness due to congenital

syphilis, 411.
Harrington, A. H. : see Farnell, F.

Harrington, A. H.
Harry, F., blood in influenza, 296.
Hart, E. B., Steeubock, H., and Ellis, N. K.,
antiscorbutic potency of milk powders,
468.
Hartwell, G. A., effect of diet on mammary

secretion, 387.
Harvier, P. : see Levaditi, C, Harvier, P.
Hasselbach, K. A,, u. Gammeltoft, S. A.,

acidosis in normal pregnancy, 537.
Haughwout, F. G., and Lantin, P. T., treat-
ment of dysentery with benzyl benzoate,
404.
Haugseth, K., Dakin's solution in treatment

of wound diphtheria, 30.
Hawk, P. B. : see Rehfuss, M. E., and Hawk,

P. B.
Hawk, P. B., Smith, C. A., and Bergeim, 0.,
nutritive value of yeast in bread, 468.
vitamine content of honey, 468.
Head, H., protopathic sensibility, 142.
Head, H., Rivers, W. H. R., and Sherren, J.,
results of experimental nerve section in
man, 46.
Heathcote, R. St. A. : see Gunn, J. A., and

Heathcote, R. St. A.
Hedblom, C. A., pulmonary abscess, 314.
Hedenius, J. : see Strandberg, J., et Hede-

nius, J.
Hedin, S. G.,proteoclastic enzymes in normal

and pathological urines, 385.
Heermann, treatment of hay fever, 310.
Hehewerth, F. H., and Kop, W. A., Wasser-
mann test in patients affected with ma-
laria in the tropics, 357.
Heissen, F., hereditary factor in bronchial

asthma, 310.
Heitz, J. : see Leriche, R,, et Heitz, J.
Hektoen, L., and Corper, H. J., effect of
mustard gas on antibody formation,
369.

Helferich, treatment of acute suppuration of

wrist, 237.
Heller, H. H., aetiology of acute gangrenous

infections of animals : a discussion of

blackleg, braxy, malignant oedema, and

whale septicaemia, 160.
Ht-nderson, L. J., blood as a physico-chemi-
cal system, 469.
see McLean, F. C, Murray, H. A., jun., and

Henderson, L. J.
Henderson, Y., apnoea after forced respira-
tion, 432.
see Haggard, H. W., and Henderson, Y.
Hendricks, H. V., chylous ascites due to

carcinoma of stomach, 8.
Hendrix, B. M., and Crouter, C. Y,, relation

of alkali reserve of blood to glycosuria

and hyperglycaemia in pancreatic dia-
betes, 173.
Hendry, R. A., antenatal syphilis, 406.
Henestenberg, W., acanthosis nigricans witli

carcinoma of internal organs, 114.
Henkel, M., umbilical diphtheria, 22.
Hennebert, C, deafness due to congenital

syphilis, 411.
Henrici, A. T., and Gardner, E. L., acid-fost

actinomycetes, with report of case from

which a new species was isolated, 261.
Henriksen, P. B., cultivation of nerve-tissue

and nerve regeneration, 351.
Heppner, M. : see Stevens, W. E., and Hepp-

ner, M.
d'Herelle, F., on nature of bacteriophagic

principle, 74.
on bacteriophagic microbe, 74.
Hering, F., toxic effects of injection of novo-

caine and bicarbonate solution into a

vein, 519.
Herman, J. L. : see Deaver, J. B., McFarland,

J., and Herman, J. L.
Hermanies, J., gonococcus types, 257.
Herring, weight of organs in pregnancy, 540.
Hertz, R., value of Wassermann reaction in

diagnosis of congenital syphilis, 412.
Herzfeld, E., non-specific horse serum in

treatment of diphtheria, 28.
Herzog, F., bothriocephalus anaemia, 108.
Herzog, F., u. Zeller, H., uromelanin and

uromelanogen, 229.
Hess, A. F., and Unger, L. J., dietaries of

infants in relation to development of

rickets, 176.
Hess, R., blood picture in whooping-cough,

202.
Hesse, E. , u. M., frequency of gall-stones,

127.
Hesse, W., auscultatory sign for diagnosis of

laryngeal diphtheria, 24. '
Hewer, E. E. : see Cullis, W. C, and Hewer,

E. E.
Hewer, R. : see Cullis, W. C, and Hewer, R.
Hewitt, J. A., effect of administration of small

amounts of thyroid gland on size and
weight of certain organs in male white
rat, 280.
Heymans, J. Y., in vivo as in vitro bacteria

pass through the walls of filters, 255.
Hildebrandt, W., chronic lung disease fol-
lowing influenza, 297.

xxvm

II. INDEX OF AUTHORS

Hill, A. v., tetanic nature of voluntary con-
traction of human muscle, 530.
Hill, L., and McQueen, J. M., measurement

of capillary blood-pressure in man, 166.
Hinman, F., diverticula of bladder, 184.
Hirai, K., formation of paraoxyphenylacetic
acid and paraoxyphenylacrylic acid from
laevo-tyrosin by bacteria, 473.
Hlrsch, E. F., changes in leucocytes and
alkali reserve of blood in experimental
infections, 368.
Hirsch, E. F., rigor mortis in smooth muscle
and a chemical analysis of fibromyoma
tissue, 280.
Hitzenberger, K. : see Brunn, F., Hitzenber-

ger, K., u. Saxl, P.
Hober, R., electromyogram in hemiplegia,

533.
Hoffmann, E., urticaria produced by flea-
bites, 113.
Hoffmann, P., electromyogram in, and func-
tion of, tendon reflexes, 531.
Hoffmann, V., results of treatment of cancer
of breast by excision and radiation, 422.
Hoffmann, W.. intestinal obstruction due to

ascarides, 104.
Hofmann, F. B., theory of smell : parosmia,

281.
Holker, J., methods of measuring opacity of

liquids, 580.
Holland, neurosyphilis, 60.
Holland, E., melanotic cancer of vulva, 233.
HoUande, A. Ch., formation of melanin in the

blood of some insects, 230.
Hollo, J., experiments on source of variations
in reaction of normal human urine, 385.
Holmes, A. D., and Deuel, H. J., jun., diges-
tibility of some hydrogenated oils, 282.
Holmes, J. B., congenital obliteration of bile-
ducts, 128.
Honeywell, H. E. : see Scott, E. L., and

Honeywell, H. E.
Hooker, D. R., functional activity of capil-
laries and veins, 278.
Hopkins, F. G., auto-oxidizable constituent of
cell, 573.
effect of heat and aeration upon fat-soluble

vitamine, 84.
vitamine content of milk, 84.
Hoppe, E. : see Maltaner, F., and Hoppe, E.
Horiuchi, Y., studies on blood-fat. I. Varia-
tion of blood-fat constituents of rabbits
under normal conditions. II. Lipaemia
in acute anaemia, 88.
Hornowski, J. : see Rothfeld, J., Freund, J.,

u. Hornowski, J.
Hornus, P., amoebic dysentery in Morocco,

402.
Horsley, V. : see Spencer, W. G., and Hors-

ley, V.
House, S. J., haemorrhagic meningo-encepha-
litis in anthrax : a report of three cases,
161.
Houzel et Sevestre, pulmonary gangrene

cured by anti-gangrene serum. 316.
Howell, K. M., and Eby, H., tramission of
specific immune bodies from mother to
young, 164.
Hufnagel. L. : see Berg6, A., et Hufnagel,L.

Hume, E. M., comparison of growth-promo-
ting properties for guinea-pigs of certain
diets consisting of natural foodstuffs,
386.
investigation of antiscorbutic value of full
cream sweetened condensed milk by ex-
periments on monkeys, 387.
Hunt, Reid, some factors relating to toxic

action of arsphenamine, 580.
Huntemiiller, epidemic of diphtheria in 19th

Bavarian Infantry Regt., 18.
Hunter. W., Serbian epidemics of typhus in

1915, 191, 198.
Hurst, A. F., gastric and duodenal ulcers, 5.
psychology of special senses and their func-
tional disorders, 53.
treatment of constipation, 221.
treatment of duodenal ulcer, 14.
Hussey, H. : see Williams, A. W., Unneberg,

A., Goldman, A., and Hussey, H.
Hussey, R. G. : see Murphy, J. B., Nakahara,

W., Hussey, R. G., and Sturm, E.
Huston, J.: see Bunting, C. H., and Huston, J.
Hutinel, J. : see Labbe, M., et Hutinel, J.

lancoresco, N. : see Widal, P., Abrami, P., et

lancoresco, N.
lizuka, N. : see Aoki, K., u. lizuka, N.
Imrie, C. G., and Graham, S. G., fat-content

of embryonic livers, 88.
Irala, J., investigations on phagocytosis, 460.
Isaac, C. L., keratodermia blennorrhagica,

110.
Isaicu : see Levaditi, C, Marie, A., et Isaicu.
Ivens, F., serum treatment of gonorrhoea, 216.
Iversen, P., experiments upon distribution of

phosphates between blood corpuscles and

plasma in vivo and in vitro, 469.
Iyer, S. R., generalized vaccinia in Burmese

children, 208.
Izar, G., acetone and diacetic acid in urine in

pneumonia, 299.

Jacki, E., epidemic of Shiga bacillusdysentery

in Heidelberg Children's Clinic, 400.
Jackson, H. : see Palmer, W. W.,Salvesen,H.,

and Jackson, H.
Jackson, J. H., evolution and dissolution of

nervous system, 141.
Jacobi, W., mental disturbances in tumours

of the basal ganglia, 447.
Jacoby, A., treatment of gonorrhoea in women,

215.
Jacod, M., intracranial extension of sarcomata

of Eustachian tube : syndrome of petro-

sphenoidal junction, 242.
Jacquelin, A. : see De Jong, S. I., et Jacquelin,

A.
Jager, R. : see Kolmer, J. A., Davis, L. C,

and Jager, R.
Jagic, N., u. Schiflfner, 0., gonococcal infection

of the heart, 211.
Jaksch-Wartenhorst, R., immunity against

influenza, 304.
Jamin, F., u. Stettner, E., influenza in chil-
dren, 303.
Janney, N. W., treatment of diabetes, 504.

II. INDEX OF AUTHORS

XXIX

Janney, N. W,, and Newell, R, R., diabetes
and tuberculosis, 500.

Janssen. H., diphtheria of mouth, 19.

Japiot, P., et Bussy, L., simplified technique
for radiotherapy of eye, 683.

Jardet, parotid swelling due to denture, 3.

Jeans, P. C, treatment of congenital syphilis,
416.

Jeliflfe, S. E., multiple sclerosis and psycho-
analysis, 441.

Jennicke, E., dysentery epidemic in Thiirin-
gen, 399.

Jensen, J. : see Cliievitz, 0., Jensen, J., Royn,
A., and Collin, E.

Jephcott, H., and Bacliarach, A. L., anti-
scorbutic value of dried milk, 387.

Joerdens, G., spontaneous pneumothorax, 319.

Johns, C. 0., and Finks, A. J., studies in
nutrition. V. Nutritive value of soy
bean flour as supplement to wheat flour,
468.

Johnson, S. E., and Mason, M. L., first
thoracic white ramus communicans in
man, 446.

Joltrain, E., complement-fixation test for
diagnosis of plague, 361.

de Jong, S. I. : see Bezan9on, F., et de Jong,
S. I.

De Jong, S. I., ct Jacquelin, A., pleuritic
hemiplegia. 319.

Jordan, E. O., and Sharp, W. B., effect of
vaccination against influenza and some
other respiratory infections, 564.

Jores, L., experimental investigations on in-
fluence of mechanical compression on
bones, 369.

Jorge, R., typhus in Portugal, 193.

Joslin, E. P., frequency of diabetes in U.S.A.,
498.
obesity preceding diabetes, 503.

Josse, M. H., pulmonary radioscopy and
radiography, 581.

Jotten, K. W., relative toxicity of different
strains of Gonococcxis, 210.

Kahn, M., angina pectoris in diabetic patients,

499.
Kalberlah, F., aetiology and disseminated

sclerosis, 149.
Kaneko, R., u. Morihana, S., researches on

identity of Spirochaeia iderohaetnotrhagiae

(Inado and Ito) and Sp. iderogem.es (Uhlen-

huth and Fromme) and the relation of

Sp. hcbdomadis, the cause of seven-day

fever (Nanukayami), to Sp. iderogenes,

455.
Kantor, J. L., intra-intestinal treatment of

hookworm infection, 107.
Karsner, H. T., and Swanbeck, C. E., removal

of particulate matter from pleura, 462.
Kastner H., results of treatment of cancer of

breast by excision and radiation, 422.
Kaufman, I., myelinization of posterior

column of cord, 547.
Kausch, W., aneurysm of vertebral artery,

333.
Kaya, A., and Starling. E. H., effects of

asphyxia on spinal animal, 429.

Kayser-Petersen : see Trcupel u. Kayser-

Petersen.
Kehrer, E., calcium content of blood in

toxaemias of pregnancy, 543.
Keidel, A., and Moore, J. E., intraspinal

treatment of neurosyphilis with salvar-

sanized serum, 339.
Keisman, M., splcnogenous thrombopenia,

124.
Keith, A., function of large intestine, 222.

see Spencer, W. G., and Keith, A.
Kellas, A. M. : see Haldane, J. S., Kellas,

A. M., and Kennawav, E. L.
Kelley, M.F.: seeCoca, A.'F.,andKpIIey, M.F.
Kennaway, E. L. : see Qilliatt, W., and

Ken n away, E. L.
see Haldane, J. S., Kellas, A. M., and

Kennaway, E. L.
Kepinow, L. : see Weinberg, M., et Kepinow,

Xj.

Ker, C. B.. intra-muscular route for injection
of diphtheria antitoxin, 28.

Kersten, H. E., treatment of typhus by in-
travenous injections of collargol or 'ful-
margin ', 198.

Kestner, O., action of irradiation on blood-
pressure, 278.
active factor in high altitudes, 278.

Kieffer, O., pulmonary disease and influenza,
302.

Kiendl, W., use of tuberculin and quinine in
lupus erythematosus, 112.

Kiessling, W., comparative experiments upon
the effect of some chlorine derivatives of
methane, ethane, and ethylene upon
isolated frog's heart, 472.

King, W. G., vaccination in the tropics, 207,
208.

Kipp, H. A., variation in cholesterol content
of serum in pneumonia, 87.

Kirby, G. H., and Davis, T. K., psychiatric
aspects of epidemic encephalitis, 447.

Kirch, A., enlarged mediastinal glands in
influenza, 298.

Kirmisson, E., anterior dislocation at elbow,
42.

Kissmeyer, A. , effects of light baths on vitiligo,
111.

Kleberger, K., pneumonomycosis aspergillina
after influenza, 298.

Kleeblatt, F., indications for splenectomy,
124.

de Kloijn, A., tonic labyrinthine and nock
reflexes of eyes, 151.

de Kleijn, A., u. Magnus, R., functions of the
otoliths. I. The place <>f otoliths in tonic
labyrinth reflexes. II. Separate removal
of otoliths in the guinea-pig, 152.
labyrinthine reflexes to progressive move-
ments, 151.

Kleinsclimidt, K. , diathermy in treatment of
whooping-cough, 203.

Kleitmann, N. : see Scott, E. L., and Kleit-
mann, N.

Klemperer, G., influenzal nephrosis, 299.

Koch, H., rashes in diabetic children, 500.

Kocher, A., anterior dislocation at elbow, 41.

Kodama, R. , ocular reactions in anaphylaxis,
164.

XXX

II. INDEX OF AUTHORS

Koettlitz, H., primary sarcoma of stomach, 9.

Kofman : see Cluzet, Rochaix, et Kofman.

Kohda, K., cultivation of B. leprae, 558.

Kolmer, J. A., Davis, L. C, and Jager, R.,
influence of chaulmoogra oil on tubercle
bacillus, 262.

Kongsted, E., comparative value of methods
of Herman and Ziehl-Neelsen for stain-
ing tuberole bacilli, 83.

Kop, W. A. : see Hehewerth, F. H., and Kop,
W. A.

Korbsch, R., u. Gross, A., vaccine treatment
of dysentery, 404.

Kossel, A., u. Giese, G., colouring matter in
chloroma, 579.

Kowallek, A., plethysmographic investiga-
tions on effects of high-frequency
currents, 279.

Kraft, A., haemolytic streptococci of appendix
vermiformis, 257.

de Kraft, F., action of electric currents on
endocrine glands and other tissues, 99.

Kramer, P. H., importance of lice in trans-
mission of typhus, 194.
epidemic of typhus in Rotterdam, 1919,

192.
incubation period of typhus, 192.

Kreuter, E., osteochondritis deformans
juvenilis coxae, 39.

Krogius, A., studies in genesis of Dupuytren's
contraction, 52.

Kroh, F., injury causing spasmodic contrac-
tion of arteries, 35.

Kromayer, E., diphtheria of vulva, 20.

de Kruif, P. H., dissociation of microbic
species. I. Coexistence of individuals of
different deg:rees of virulence in cultures
of bacillus of rabbit septicaemia, 568.

Krumbhaar, E. B., and Masser, J. H., jun.,
studies of the blood of normal monkeys,
572.

Krumwiede, C. : see Park, W. H., Williams,
A. W., and Krumwiede, C.

Kunstmann, erythromelalgia, 113.

Kiintzel, 0., tar cancer, 114.

Kuramitsu, C, and Loeb, L., involution of
uterus following labour, and influence of
castration and suckling on process of in-
volution, 474.
effect of suckling and castration on lacta-
ting mammary gland in rat and guinea-
pig, 474.

Kiittner, H., gunshot wound of vertebral
artery, 330.

Kiittner, H., u. Baruch, M., injury causing
spasmodic contraction of arteries, 33, 36.

Labbe, M., diabetic epilepsy, 499.

Labbe. M.. et Hutinel, J., two cases of typhus

in Paris, 193.
Laboure, J., injury to external carotid during

removal of tonsils, 327.
Ladwig, B. : see Borchardt, L., u. Ladwig, B.
Lafaye, A., treatment of infantile syphilis

with intravenous injections of neo-

salvarsan, 415.
value of luetin reaction in diagnosis of

congenital syphilis, 412.

Lakaye, neurosjrphilis after regular and
sufficient arsenical treatment in primary
stage, 336.

Lane, C, ankylostomiasis in Darjeeling dis-
trict, 106.

Lane, W. A., surgical treatment of intestinal
stasis, 221.

Langeiaan, J. W., muscle tonus, 532.

Langfeldt, G., blood-sugar regulation and
origin of hyperglycaemias. I. Glycogen
formation and glycogenolysis. II. Con-
ditions of action of liver diastases. III.
Theory, 470.

Lantin, P. T. : see Haughwout, F. G., and
Lantin, P. T.

Lanzilotta, R., use of ultra-violet rays in the
preparation of vaccines, 356.

Lambert, diphtheria of middle ear, 19.

Lapin, J., et Senevet, G., Weil-Felix reaction
in typhus, 197.

Laquerriere : see Delherm et Laquerriere.

Laqueur, E., and Magnus, R., experimental
pathology and therapy of phosgene poison-
ing, 384.

Laska-Mintz, E. : see Parnas, J. K., u. Laska-
Mintz, E.

Lauenstein, R., treatment of injuries to
vertebral artery, 332.

de Laulerie : see Ribadeau- Dumas, Mallet, et
de Laulerie.

Laura, C. L., serum treatment of diabetes,
507.

Lauritzen, M., treatment of diabetes, 504,
506.

De Lavergne, diphtheritic paralysis, 24.
see Besson, A., et de Lavergne.

De Lavergne et Zoeller, Shick test of suscepti-
bility to diphtheria, 26.

Liiwen, A., u. Reinhardt, A., oxyuriasis of
appendix, 105.

Le Bon, G., certain antagonistic properties
in different regions of spectrum, 396.

Lecene, P., et Lhermitte, J., cerebral soften-
ing from metallic embolus in left middle
cerebral artery, 251,

Lederer, K., pseudo-membranous oesophagitis,
299.

Lederer, R. . painting throat with solution of
silver nitrate in treatment of pertussis,
203.

Leendertz, G., diphtheria of vagina and skin
of intragluteal folds, 20.

Leete, H. M., Shick test for susceptibility to
diphtheria, 26.

Lefeuvre : see Marquis et Lefeuvre.

Legs, A. T., non-tuberculous juvenile coxal-
gia, 38.

Legrand, H., multiple amoebic abscesses,
403.

Legrand et Auguste, C, seropurulent effusion
in pleura in influenzal pneumonia, 298.

Legry, Courcoux, et Lermoyez, J., outbreak
of mild typhus in a home for foreign
workmen in Paris, 193.

Lehmann u. Scheven, results of treatment of
cancer of breast by excision and radiation,
422.

Leimdiirfer, A., skin eruptions in influenza,
300.

II. INDEX OF AUTHORS

XXXI

Lemann, 1,1,, case of Shiga bacillus dysentery
with pseudo-membrane in vagina, and
oedema of abdominal wall, 402.

Lemon, W. S., angioma of stomach, 10.

Lenhardt, C. H. : see Marine, D., and Len-
hardt, C. H.

Lennhoff, C, inoculation for psoriasis, 110.

Lenorm.ant, C, cutex verticis gyrata, 114.
diffuse sclerosis of skin and of cellular
tissue of neck following prolonged radio-
therapy : cicatricial torticollis, marked
oedema of face, laryngotracheal com-
pression, 391.
gas cysts of intestine, 11.

de L^obardy, J. : see Agulhon et do Leo-
bard y, J.
see Ribierre, P., et de Leobardj-, .T.

Leriche, K., et Heitz, J., injury causing
spasmodic contraction of arteries, 33.

Lermoyez, J. : Legry, see Courcoux, et Ler-
moyez, J.

Levaditi, C., et Harvier, P., experimental
study of lethargic encephalitis, 148, 262.

Levaditi, C, Marie, A., et Isaicu, researches
on spontaneous spirochaetosis of rabbit,
569.

Levene, P. A., and Rolf, I. P., lecithin of
brain, 473.

Levin, I.: see Cohen, M., and Levin, I.

Levy, C. S., congenital absence of a lung, 309.

Levy, P. P., interpretation of blood-cultures,
458.

L4vy-Bing, A., et Duroeux, L., arsenical com-
pounds in treatment of gonorrhoeal
salpingitis, 216.

Levy-Franckel, A., splenomegaly following
injection of neosalvarsan, 122.

Lewis, D. S., and Mason, E. H. , diastatic
ferments of blood, 87.

Lewis, H. B. : see Stearns, G. , and Lewis, H. B.

Lewis, W. H., and Webster, L. T., giant cells
in cultures from human lymph nodes,
370.

Lewy, F. H.: see Cassirer, R., u. Lewy, F. H.

Lhermitte, J. : see Lecene, P., et Lhermitte, J.

Lian, C, et Cathala, J., vagotonia in asthma,
312.

Lichtenstein, A., pyloric spasm, 7.

Lichtenstein, S., case of spontaneous tuber-
culosis in frog, 84.

Lieben, F. : see Fiirth, 0., u. Lieben, F.

Liebhardt, E., demonstration of active tuber-
culosis by Wildbolz's auto-urine reaction,
559.

Liljestrand, G., u. Magnus, R., physiology of
muscular spasm in tetanus, 533.

Lilly, T. E., Schick test for susceptibility to
diphtheria, 25.

Lindburg, G., post-traumatic serous menin-
gitis in children, 253.

Lindstedt, F., contribution to pathogenesis of
sciatica, 254.

Linzenmeier, G., investigations on rate of
sedimentation of red blood corpuscles,
175, 543.

Litch, V. M., and Meyer, K. F., spontaneous
epidemic among laboratory rabbits caused
by paratyphoid B bacillus related to
rodent group, 80.

Lloyd, J. H., syphilis of eighth nerve, 447,

Loeb, L. : see Kummitsu, C, and Loeb, L.

Loeb, L., and Kuramitsu, C, influence of
lactation on sexual cycle in rat and
guinea-pig. 475.

Loeper, M., Forestier, J., et Tonnet, .T.,
paradoxical hyperalbuminosis in blood
of cmncer subjects, 466.

Loeweimardt, F. E. R., aetiology of influenza,
1.55.

Liiffler, \V., liver function under experimental
patholo'.^ical conditions, 542.
see Bloch, Br,, u. Loffler, W.

Logan, W. R. : see Cranston Low, R., Logan,
W. R., and Rutherford, A.

Loiseleur, .J., pulmonary gangrene cured by
artificial pneumothorax, 316.

Lomholt, S., prostitution and alcohol in
causation of gonorrhoea, 210.

Looft, C, diphtheria in the new-born, 21.
umbilical diphtheria, 22,

Lord, F. T., pulmonary abscess, 315.

Lortat- Jacob, ciyocautery, 114.
influenza in old pleuritics, 302.

Losee, J. R., and van Slyke, D., toxaemias of
pregnancy, 537 et seq.

Losio, L., haemolytic jaundice with spleno-
megaly, 123.

Lotsch, F., osteo-myelitis of hyoid after in-
fluenza, 301.

Loughlin, R. : see Daniels, A. L., and Lough-
lin, R.

Low, G. C. , diagnosis of dysentery, 403.

Lowe, E. C, membranous colitis in influenza,
299.

LiJwy, R., a typical typhus, 194,

Liiain, M., reflex gastrospasm, 129,

Lubarsch, 0., melanotic cancer in animals,
233.

Lubinski, H., bacteriology of wound diph-
theria, 162.

Luccarelli, V., war splenomegaly, 121.

Liiers, N,, general colloid test in cerebro-
spinal fluid and use of Congorubin, 479.
Lumiere, A., et Chevrotier, J., simple and
harmless method of preventing anaphy-
lactic shock, 458.

Lundegaard, K. K. K., universal light baths
in ophthalmology, 346.

Lusk, G., production of fat from protein, 86.

Lynch, V., chemistry of whitefish sperm, 89.

Lyon, R. H. : see Beckwith, T. D., and Lyon,

R. H.
Lyter, J. C, non-tuberculous lung infection,
314.

Maaltic, C. U., practical value of Eisner's
gastroscopy, 439.

McCann, W. S., observation of effect of pro-
tein meal given to a man at end of 8-day
fast, 86.

McCarty, E. D. : see McClure, C. W., and
McCarty, E. D.

Maccarty, W. C, pathological changes in
4,998 removed gall-bladders, 126, 128.

McCaskey, D., quartz ultra-violet therapy
and kinetic energy, 391.

Macchi, A. : see Zenoni, C, e Macchi, A.

XXXll

11. INDEX OF AUTHORS

McClure, C. W., and McCarty, E. D., roent-
genographic studies in gout, 484.

McCoUum, E. V., Simmonds, N., Parsons,
H. T., Shipley, P. G., and Park, E. A.

I. Production of racliitis and similar
diseases in the rat bj' deficient diets.

II. Effect of cod-liver oil administered
to rats with experimental rickets, 176.

McConnell, A. A., fatal case of sphnectomy
for cirrhosis of liver, 124.

McDonagh, J. E. R., varieties of ulcus moUe,
218.
tieatment of ulcus molle, 220.

Macdonald, E. L. : see Alexander, M. E., and
Macdonald, E. L.

McFarland, J. : see Deaver, J. B., McFarland,
J., and Herman, J. L.

Macht, D. I., benzyl benzoate in treatment
of whooping-cough, 203.

Mcintosh, J., transmission of experimental
encephalitis lethargica in series in mon-
keys and rabbits, with notes on sponta-
neous infection in monkey, 65.

McJunkin, F. A., tuberculin hypersensitive-
ness in non-tuberculous guinea-pigs in-
duced by injections of bacillus-free
filtrates, 558.

Mackay, H. M. M., effect on kittens of a diet
deficient in animal fat, 386.

Mackenzie Wallis, R. L., toxaemias of preg-
nancy, 540.

McKhann, C. F. : see Rockwell, G. E., and
McKhann. C. F.

McKibben, P. : see Weed, L., and McKibben.
P.

Mackie, T. J., and Rowland, C. C, value of
simultaneous testing for Wassermann
reaction with two different antigens and
' ice-box method ', 58.

McLean, F. C, Murray, H. A., jun., and
Henderson, L. J., variable acidity ot
haemoglobin and distribution of chlorides
in blood, 88.

McLean, S., intestinal parasites in young
children in New York, 103.

MacLeod, C. : see RoUeston, J. D., and
MacLeod, C.

MacLeod, J. J. R. , concentration of lactic
acid in blood in anoxaemia and shock.
376.
periodic breathing and effects of oxygen
administration in decei'ebrate cats, 383.

McMurray, T. E., benzyl benzoate in treat-
ment of whooping-cough, 203.

McQueen, J. M. : see Hill, L., and McQueen,
J. M.

Magner, W. , complement- fixation test for
gonorrhoea, 212.

Magnus, R., choline, hormone of intestinal
peristalsis, 479.
see de Kleijn, A., u. Magnus, R.
see Laqueur, E., and Magnus, R.
see Liljestrand, G., u. Magnus, R.

Maisonneuve et Favrat, ligation of vertebral
artery, 330.

Maitland, H. B., Cowan, M. L., and Det-
weiler, H. K., aetiology of epidemic
influenza: experiments in search of
filter-passing virus, 67.

Maitland, H. B., Cowan, M. L., and Det-
weiler, H. K., spontaneous and artificial
pulmonary lesions in guinea-pigs, i*abbits,
and mice, 154.
Makins, G. H., aneurysm and cerebral em-
bolism following gunshot injury, 328.
arteriovenous aneurysm, 322.

Mallet : see Ribadeau-Dumas, Mallet, et de
Laulerie.

Mallory, W. J., amoebic dysentery, 402.

Malone, J. Y. : see Sachs, E., and Malone, .T. Y.

Maltaner, F., and Hoppe, E., chemotactic
effect of osmosis upon leucocytosis, 362.
osmosis as factor in local accumulation of
leucocytes in body, 90.

Mandlebaum, F. S., and Downey, H., histo-
pathology of Gaucher's disease, 120.

Manini, L., treatment of amoebic abscess of
liver, 404.

Manoukhin, I. I., ti-eatment of Infectious
diseases by leucocytolysis produced by
rontgenization uf spleen, 485.

Manson-Babr, P., monartliritis or poly-
arthritis as complication of bacillary
dysentery in Egypt and Palestine, 400.

Marfan, A. B., asthma in children, 311.

Marie, A. : sec Levaditi, C, Marie, A., et
Isaicu.

Marie, P. L. : see Armand-Delille, P. F., et
Marie, P. L.

Marine, D., and Lenhart, C. H., effects of
adrenalin on respiratory exchange, 274.

Marquis et Lefeuvre, anastomosing current
after ligature of common carotid, 329.

Marriott, W. M., post-diphtheritic paralysis
of respiratory muscles, 24.

Marsh, P. L. : see Newburgh, L. H., and Marsh,
P. L.

Marshall, E. K. : see Rowntree, L., Chesney,
A. M., and Marshall, E. K.

Martin, L., antitoxin treatment of diphtheria,
27.

Martindale, L., intensive X-ray therapy versus
hysterectomy for fibromyomata of uterus,
95.

Mason, E. H. : see Lewis, D. S., and Mason,
E. H.

Mason, F. R. .ipecac sensitization and bron-
chial asthma, 310.
treatment of bronchial asthma with benzyl
benzoate, 312.

Mason, M. L. : see Johnson, S. E , and Mason,
M. L.

Mason, V. R., bronchial spirochaetosis, 313.

Masser, J. H., jun. : see Krumbhaar, E. B.,
and Masser, J. H., jun.

Mas V Magro, F.,blood picture in anaphylaxis,
358.

Matas, R., aneurysm of vertebral artery, 330.

Mathieu, P., cholecystogastrotomy, 131.

Mathison, G. C, action of asphyxia on spinal
animal, 429.

Matsumoto, M., experiments upon the pro-
duction of antihuman haemoljsin with
special reference to immunization with
erythrocytes sensitized with heated
serum, 165.

Matsunaga, T., diffuse pigmentation in mela-
notic cancer, 233.

II. INDEX OF AUTHORS

xxxm

Matthew, D. : see Rixon, C. H. L., and
Matthew, D.

Matthiasson, S., influenza epidemic in Ice-
land, 296.

Mattill, P. M., Mayer, K., and Sauer, L. W.,
influence of intravenous injections of
acacia-glucose solutions on urine excretion
and blood-volume in rabbits, 277.

Mattirolo, G., e Bertololti, M., rare malforma-
tion of cephalic end of vertebral column,
370.

Mauelshagen, F. : see Habermann, R., u.
Mauelshagen, F.

May, E. : see Widal, F., et May. E.

Mayer, K. : see Mattill, P. M., Mayer, K.,and
Sauer, L. W,

Mayer, L., acute haematorrhagic pancreatitis
with necrosis, 510.

Mayer, M., examination of blood and stools
of coloured prisoners of war, 105.

Mayo, C. H., union of hepatic duct with duo-
denum, 131.
mortality from cholecystectomy, 126.

Mayo, W. J., splenic anaemia, 119.

Mead, S. W. : see Dutiker, R. A., Eckles,
C. H., Dahle, C. H., Mead, S. W., and
Schaefer. 0. G.

Meader, P. D. : see Robinson, G. H., and
Meader. P. D.

Meader, P. D., and Robinson, G. H., biological
and physical properties of haematoxin
of streptococci, 69.

Meek, W. J., and Eyster, J. A. E., reactions to
haemorrhage, 470.

Megaw, J. W. D., hookworm infection in
United Provinces of India, 106.

Meier, K. : see Straub, H., u. Meier, K.

Melman, R. J., tabes mesenteria following
influenza, 302.

Menard, pregnancy after radiotherapy for
fibroid, 95.

Mendel, L. B. : see Osborne, T. B., and
Mendel, L. B.

Mengert, E., silver-salvarsan in treatment of
congenital syphilis, 416.

Menninger, K. A., influenza and hypophrenia,
300.

Mensching, H., results of vaccination of 684
infants in Obstetrical Institute at Ham-
burg, 206.

Menten, M. L., variations in benzidin per-
oxidase reaction depending on fixative,
physiological activity, and type of animal,
68.

Mercade, S., end to end ileo-sigmoidostomy,

140.
Mark, L., Recklinghausen's disease, adenoma
sebaceum, and tuberous sclerosis caused
by infection with some dicotyledonous
plant, 114.
Metalnikow, S. , on natural and acquired
immunity in larva of Galleria mellonella,
82.
Metchnikoff, E., function of large intestine,

222.
Meyer, A. H., report of whooping-cough in-
vestigations at State Serum Institute at
Copenhagen, 561.
diphtheria prophylaxis, 26.
IV.

Meyer, A. \V., toxic effects of injection of

novocaine and bicarbonate solution into

a vein, 518.
Meyer, B. I. : see Gray, G. A., and Meyer,

B.I.
Meyer, H., non-specific horse serum in treat-
ment of diphtheria, 28.
see Frohlich, A., u, Meyer, H.
Meyer, K. F. : see Litch, V. M., and Meyer,

K. F.
Mhaskar, K.S., hookworm infection in Tanjore,

Trichinopoly, Madura, and Ramnad, 106.
sec Caius, J. F., and Mhaskar, K. S.
Michon, L. : see Forestier, J., et Michon, L.
Miescher, G., malignant melanoma of skin,

234.
Mignot, R. : see Renon, L., et Mignot, R.
Milani, E., bactericidal action of secondary

rays from colloidal metals, 94.
Milio, G., blood in influenza, 297.
Miller, D. A. : see Young, J., and Miller,

B. A.
Miller, R., and Perkins, H., congenital

steatorrhoea, 509.
Ministry of Health, report on influenza

pandemic of 1918-19, 296.
Mishulow, L. : see Cooper, G. M., Mishulow,

L., and Blanc, N. E.
Mitchell. J. W. : see Allen, F. M., Mitchell,

J. W., andSherrill, J. W.
Montgomery, D. W., and Culver, G. D., eczema

of vermilion border of lips, 111.
Moog, 0., u. Worner, E.,Trichocephalustrichiurus

in soldiers, 107.
Moore, J. E. : see Keidel, A., and Moore, J. E.
Moore, R. F,, melanoma and melanotic cancer

of eye, 235.
Moorhead.T. G., myelitis in dysentery patient,

402.
Montel, L. R., local application of anti-
streptococcic serum in treatment of

chronic sepsis of skin. 111.
Monziols et Collignon, treatment of typhus

with iodized Proteus X 19 vaccine, 199.
Morenas: see Bonnet, L. M., et Morenas.
Morihana, S. : see Kaneko, R., u. Morihana,

S.
Moro, E., sudden death in eczema, 111.
Morrison, L. F. : see Gay, F. P.,and Morrison,

L. F.
Morriston Davies, H. : see Trotter, W., and

Moriston Davies, H.
Mosenthal, H. O., and Wiener, H. J., dietetic

treatment of diabetes, 505.
Moszeik, lethargic encephalitis following

typhus, 195.
Mott, F., CO poisoning, 430.
Mott, F. W., symptoms of syphilis in cases of

juvenile general paralysis and tabes,

412.
Mottram, J. C, red cell content of those

handling radium for therapeutic pur-
poses, 93.
histological changes in bone-marrow of rats

exposed to 7-radiations from radium, 93.
see Cramer, W., and Mottram, J. C.
Mouchet, A., inflammation of tarsal scaphoid

in young children (Kohler's disease),

483.

XXXIV

II. INDEX OF AUTHORS

Mouchet, A., infantile osteo-chondritis de-
formans of upper epiphysis of femur,
481.

Mouriquand, G., et Bertoyo, trichocephaliasis
with severe anaemia and diarrhoea, 108.

Mueller, J. H., bacterial metabolism, 90.

Miiller, E. F., fatal cases of influenza com-
plicated by infection with Aspergillus
fumigatus, 298.

Miilier, H.. treatment of gonorrhoea by intra-
muscular injections of turpentine and
' aolan ', 214.

Miilier, S., enterostomy for post-operative
intestinal obstruction, 440.

Muraud, J., treatment of acute suppuration
of wrist, 237.

Murphy, J. B. : see Nakahara, W., and
Murphy, J. B.

Murphy, J. B., Hussey, R. G., Sturm, E.,
Nakahara, W., effect of induced cellular
reaction on fate of cancer grafts, 488.

Murphy, J. B., Nakahara, W., Sturm, E.,
relation between time and extent of
lymphoidstimulation induced by physical
agents and degree of resistance to cancer
in mice, 489.

Murphy, J. B., Nakahara, W., Hussey, R. G.,
Sturm, E., effect of cellular reaction in-
duced by X-rays on cancer grafts, 488.

Murray, H. A., jun. : see McLean, F. C,
Murray, H. A., jun., and Henderson,
L.J.

Murstad, E., Sachs-Georgi syphilis reaction,
361.

Musumeci, G., e Di Macco, G., insensible
perspiration through cutaneous scars and
skin of paretic limbs. 370.

Naccarati, S., oculo-cardiac reflex (Dagnini-
Aschner phenomenon) — its use in
medicine and psychology, 150.

Naessens, subcutaneous injections of oxygen
in treatment of influenzal broncho-
pneumonia, 305.

Nagao, K., fate of india ink injected into
blood, 171,

Nageotte, J., et Sencert, L., grafts of dead
tendon, 527.

Nakahara, W. : see Murphy, J. B., Nakahara,
W., Hussey, R. G., Sturm, E.

Nakahara, W., and Murphy J. B., influence
of cancer inoculation on lymphoid stimu-
lation induced by small doses of X-rays,
489.
effect of small doses of X-rays of low
penetration on resistance of mice to
transplanted cancer, 489.

Nanta, A., et Baudru, L., lymphadenoma with
pruritus, 114.

Nasso, I., spasmodic sneezing in whooping-
cough, 201.

Nathan, E., production of antibodies in tricho-
phytic infection, 112.

Naunyn, B., relation of jaundice to revaccina-
tion, 209.

Neal, H. V., nerve and plasmodesma, 445.

Neame, H., treatment of interstitial keratitis
due to congenital syphilis, 411.

Negelein, E. : see Warburg, 0., u. Negelein, E.
Neher, R., results of treatment of cancer of

breast by excision and radiation, 422.
Neilson, I. L. : see Waite, .J. H., and Neilson,

I. L.
Neri, V., semeiologicalimportanceof electrical
examination of cutaneous sensibility,
490.
Netter, A., et Salanier, M., case of typhus

contracted in Poland, 193.
Neugebaur, volvulus of sigmoid flexure,

227
Neuberg, C, Nord, F. P., u. Wolff, E.,
acetaldehyde as intermediary substance
in fermentation of sugar by B. lactis
aerogen^e, 388.
Neuber, E., gastric myomata, 10.
Neubiirger, K., post-mortem pigmentation of

skin, 112,
Neuda, P., syphilis and influenza, 302.
Neudorfer, A., treatment of volvulus of

sigmoid flexure, 227.
Neumann, J., u. Zoepffel, H., diaphragmatic
pleurisy in influenza simulating perfora-
tive peritonitis, 301.
Neumann, M., helminthiasis in infants,

103.
Nevin, Mary, botulism from ch^'ese, 353.
Nevin, M. : see Williams, A. W., Nevin, M.,

Gurley, C. R.
Newburgh, L. H., and Marsh, P. L., dietetic

treatment of diabetes, 506.
Newell, R. R. : see Janney, N. W., and Newell,

R. R.
Nicolaysen, K., irritation of vagus and haemo-

rrhagic erosions of stomach, 5.
Nicolaysen, N. A., case of rat-bite fever,

271.
Nicoll, J. H., chronic pancreatitis. 510.
Nicolle, C, et Conseil, E., use of serum of
typhus convalescents in prophylaxis of
typhus, 197.
prophylactic vaccination against Malta
fever, 256.
Nicolle, C., et Cuenod, A., experimental

trachoma, 462.
Ninni, C, a new anaerobic soil bacillus
{B. spermoides), 160.
size of spores of soil bacteria, 159.
on flora of small intestine of small herbivora,
with special reference to presence in it
of B. coH, 76.
Nitch, C. A. R., and Shattock, S. G., diffuse

emphysema of intestinal wall, 10.
Nogier, T., radium therapy for uterine

fibroids, 285.
Noire, H., precautions to be taken in X-ray

therapy of ringworm, 112,
Nonne, M., myeloma of spine, 250.
Nonnenbruch, blood after administration of

urea, 277.
Nord, F. F. : see Neuberg, C, Nord, F. F., u.

Wolff', E.
Novak, E., polypoid adenoma of stomach, 10.
Novaro, P., calorimetrie investigations on
inanition and deficiency disease, 167.
changes in the interstitial tissue of testicle
in consequence of deficiency in water-
soluble accessory substance B, 168.

II. INDEX OF AUTHORS

XXXV

O'Donovan, W. J., dermatitis due to Carpo-
glyphits passidarum in persons handling
figs, 113.
tar cancer, 113.

Oehme, C, secretion of water by kidney in
relation to general water metabolism,
575.

Offenbacher, R., investigations into the
activity of pulmonary tuberculosis by
Wildbolz's method, .>59.

Okinczye, J., volvulus of sigmoid flexure,
227.

Olitsky, P. K., and Gates, F. L., experimental
studies of nasopharyngeal secretions from
influenza patients. I. Transmission
experiments with nasopharyngeal wash-
ings. II. Filterability and resistance to
glycerol. III. Studies in concurrent
infections, 266. IV. Anaerobic cultiva-
tion, 560.

Olitsky, P. K. : see Amoss, H. L., Gates, F. L.,
and Olitsky, P. K.

Olitsky, P. K. : see Gates, F. L., and Olitsky,
P. K.

Olnier, D., et Berthier, determination of
volume of pleural cavity in course of
pneumothorax, 571.

Olsen, 0., action of blood in growth of
influenza bacillus, 156.

Ornstein, M., bacteriology of bacillus of
Schmitz, 78.

Osborne, T. B., and Mendel, L. B., critique
of experiments with diets free from fat-
soluble vitamine, 177.
growth of diets poor in true fats, 177.
ophthalmia and diet, 574.

Osgood, H. A., X-ray interpretation of gastro-
intestinal tract, 389.

Otelesco, I. : see Weinberg, II., et Otelesco, I.

Otsubo, T., action of certain salts on phago-
cytosis and virulence of streptococci, 3C1.

Pallin, G., anatomical variation of bile-ducts,
126.
malignant disease involving bile-ducts, 129.

Palmen, A. J., case of rat-bite fever in Hel-
singfors, 271.

Palmer, W. W,, Salvesen, H., and Jackson,
H., relationbhip between plasma bicar-
bonate and urinary acidity following the
administration of sodium bicarbonate,
173, 539.

Palmer, W., and van Slyke, D., relation be-
tween alkali retention and alkali reserve,
539.

Palugyay, J., Rontgen observations on ana-
tomy and physiology of cardia, 388.

Panayotatou, A., treatment of amoebic ab-
scess of liver, 404.

Pannett, C. A., and Wilson, C. M., influence
of bile salts on gastric function, 465.

Paraf, J., transmission of dysentery by flies,
399.

Pardi, U., action of concentrated sera, 166.

Park, E. A. : see McCollum, E. V., Parsons,
H. T., Shipley, P. G., and Park, E. A.

Park, L. K. : see Eiskamp, E. H., and Park,
L. K.

Park, W. H., duration of immunity from
diphtheria, 26.
see von Shelly, A. I., and Park, W. H.

Park, W. H., and Cooper, G., accidental in-
oculation of influenza bacilli on mucous
membranes of healthy persons with
development of infection in at least one.
Persistence of type characteristics of
bacilli. 267.

Park, W. H., Williams, A. W., Krumwiede,
C, microbial studies on acute respiratory
infection, with especial consideration of
immunological types, 267.

Parker, G. H., elementary nervous system,
141, 144.

Parker, H. L., juvenile tabes, 149, 411.

Parnas, J. K., carbohydrate metaViolism of
isolated amphibian muscle, 577.

Parnas, J. K., u. L;iska-Mintz, E., influence
of subminimal stimuli upon the course of
chemical changes in muscle, 577.

Parrino, G., experimental investigations on
phagocytosis. Influence of various fixing
agents. 171.

Parsons, H. T. : see McCollum, E. V., Sim-
monds, N., Parsons, H. T., Shipley, P. G.,
and Park, E. A.

Paterson, D. H., transmission of syphilis to
third generation, 412.

Paton, D. N., and Watson, A., aetiology of
rickets, 465, 574.

Patzschke, W., treatment of gonorrhoea!
vulvo-vaginitis in children, 217.

Paul, E., splanchnic anaesthesia for gastric
operations, 524.

Paulian, D. E., Marinesco's technique for
intra-spinal treatment of neurosyphilis
with salvarsanized serum, 337.

Paullin, J. E., renal glycosuria, 502.

Pawlow, I., 'conditional' reflexes, 428.

Payr, E., constipation and its surgical treat-
ment, 222.

Pearce, L. : see Brown, W. H., and Pearce, L.

Pech, phenomena of antagonism between
diiierent rays (ultra-violet, visible spec-
trum, infra-red), 395.

Peiper, diphtheria of penis and umbilicus in
new-born infant, 23.
vulvar and cutaneous diphtheria, 20.

Perkins, H. : see Miller, R., and Perkins, H.

Permar, H. H., experimental study of mono-
nuclear phagocytes of lung, 462.

Pernet, G., post- vaccinal psoriasis, 208.

Perrin-Marechal, A., pulmonary abscess due
to pneumobacillus, 315.

Perthes, G., arteriovenous aneurysm, 331.
arthritis deformans juvenilis, 39.
ligature of arteries, 329.
results of treatment of cancer of breast by
excision and radiation, 422.

Peshkin, M. M., ipecac sensitization and
bronchial asthma, 310.

Peters, J. P., jun., and Barr, D. P., carbon
dioxide dissociation curve and arterial
and venous carbon dioxide tension of
human blood in health and in disease,
173.
respiratory mechanism in cardiac dyspnoea,
382.

c 2

XXXVl

II. INDEX OF AUTHORS

Peters, J. P., Barr, D. P., and Rule, F. D.,
carbon dioxide absorption curve and car-
bon dioxide tension of blood of normal
resting individuals, in cardiac dyspnoea,
and in severe anaemia, 381.

Peters, V.J. W., pulmonary abscess, 314, 815.

Peterson, W. H. : see Fred, E. B., and Peter-
son, W, H.

Petow, H. : see Rona, P., u. Petow, H.

Petren, K., mortality from 1918 epidemic of
influenza in Sweden, 296,
renal affection in influenzal pneumonia,
299.

Pette, H., relation of neurosyphilis to pre-
vious treatment, 335.

Petzetakis, D., parabronchial pleurisy, 318.

Peyron : see Alezais et Peyron.

P^zard, A., numerical law of regression of
certain sex characters, 179.

Pfeiffer, R., right hemiplegia in typhus, 195.

Phillips, C. E. S., suggested new method of
measuring X-ray dosage, 182.

Piccininni, F., epidemiological and anatomo-
pathological observations on rat plague.
Experimental investigations on immu-
nity of rats against plague, 459.
means of importation of plague into Italy
and preventive measures, 459.

Pickering, D. V., blood-sugar in diabetes,
502.

Pighini, G., chemical composition of brain in
dementia praecox, 479,

Pinch, A. E. H., report of work carried out
at Radium Institute, London, from Jan.
1, 1919, to Dec. 31, 1919, 96.

Pinol, E. L., bronchial spirochaetosis, 313.

Piper, I. H., nature of electroniyogram, 530.

Pirondini, E., pyelitis larvata cystalgica, 240.

Pistoechi, G., on influence of spleen, kidney,
and thyroid on anaphylactic shock, 169.

Plaut, H. C., salvarsan in treatment of pul-
monary gangrene, 316.

Plesch, J., inhalations of iodine vapour in
prophylaxis of influenza, 304.

Plichet : see Weil, P. E., et Plichet.

Plimmer, R. H. A., analyses and energy
values of foods, 673.

Pontano, T., treatment of amoebic abscess of
liver, 403.

Ponticaccia, L., experimental investigations
on haemolytic action of oleic acid and
trioleins in rabbits, 166.

Porte : see Cristol et Porte.

Poulton, E. P. : see Haldane, J. S., and Poul-
ton, E. P.

Povitsky, 0. R., and Denny, H. T., further
studies on grouping of influenzal bacilli,
with special reference to permanence of
type in carrier, 267.

Pozerski, E. : see Blanc, J., et Pozerski, E.

Pozzo, A., ' Norwegian scabies,' 113.

Prausnitz, C, bacteriology of swine eiy-
sipelas in man, 352.

Prausnitz, P. G., umbilical diphtheria, 22.

Preisendorf, F., function of tendon reflexes,
531.

Preiss, G. A., action of paravertebral injec-
tions in producing spinal anaesthesia,
523.

Price-Jones, C, diurnal variation in sizes of

red blood cells, 366.
Pritchett, T. W. : seeWishart, M. B., andPrit-

chett, T. W.
Probizer, G., pellagra in the Trentino, 113.
Proust, R., et Ramond, L., empyema caused

by rupture of amoebic abscess of liver,

403.
Prym, 0., liability of diabetics to flea-bites,

500.
Pulido, A., recent outbreaks of typhus in

Spain, 192.
Puntoni, V., tobacco smoke as disinfectant of

the mouth, 357.
Putnam, T. J. : see Foley, F. E. B., and Put-
nam, T. J.
Putnam, J. J., and Gay, D. M., behaviour of

influenza bacillus in mixed culture on

haemoglobin-free media, 156.

Quick, D., results of treatment of cancer of
breast with X-rays and radium after
excision, 420.
see Bagg, H. J., Ewing, J., and Quick, D.

Radin, M. J., chronic lung disease following

influenza, 297.
Ragoff, J. M. : see Stewart, G. N., and Ragoff,

J. M.
Rahnenfuhrer, C, clinical history of circum-
scribed pulmonary suppuration (abscess

gangrene), 581.
Ramirez, M. A., hoi-se asthma following blood

transfusion, 311.
protein sensitization in eczema, 111.
Ramond, F., pyloric spasm, 6, 184.
Ramond, F., et Clement, R., pylorospasm, 6.
Ramond, L. : see Proust, R., et Ramond, L.
Randall, S. B. : see Foster, L. F., and Randall,

S. B.
Ransohoff, J., aneurysm of internal carotid

due to peritonsillar abscess, 325.
Ransom, B. H., Ascaris lumbricoides causing

pulmonary disease, 104.
Ransom, F. : see Dixon, W. E., and Ransom,

F.
Rappleye, W. C. : see Forbes, A., and Rap-

pleye, W. C.
Rathery, F., et Binet, L., saliva in diabetic

patients, 499.
Rathery, F., et Bordet, F., pulmonary gan-
grene cured by anti-gangrene serum, 316.
Ravaut, P., et Gallerand, leucoplacia treated

by carbon dioxide snow, 114.
Ravina, A. : see Dufour, H., Semelaigne, G.,

et Ravina, A.
Rawlins, M., ti-eatment of gonorrhoea in

women, 215.
Ray, C. B. : see Shorten, J. A., and Ray, C. B.
Razzaboni, G., primary sarcoma of internal

saphenous vein, 345.
Redlich, E., pathology of epilepsy following

gunshot wounds of the skull, 448.
Reece, R. J., percentage of children vaccin-
ated, 205.
Reenstierna, J.,se rum treatment of chancroid,

220.

11. INDEX OF AUTHORS

XXXVll

Rehberg, mediastinal pleurisy, 318.

Kehfuss, M. E., and Hawk, P. B., gastric
analysis. I. Fundamental principles.
II. Interdigestive phase or principles
governing phenomena of resting stomach ,
474.
hyperacidity, 4.

Rehn, E., ligation of internal carotid, 329.

Eeiche, F., association of whooping-cough
and influenza, 201.
immunity against influenza, 304.
jaundice in influenza, 299.
mortality in whooping-cough, 201.
urticaria tuberosa, 113.
whooping-cough complicated with con-
vulsions, 202.

Reichle, splanchnic anaesthesia, 524.

Reimer, G., caramel in treatment of diabetes,
506.

Reinhardt, A. : see L"twen, A., u. Reinhardt,
A.

van der Reis, diagnosis of typhus by Fried-
berger-van der Reis, skin reaction, 197.

Reiss, J. : see Crohn, B. B., and Reiss, J.

Renaud, M., atypical primary epithelioma of
lung, 317.

Renauld-Capart, H., cerebral metabolism.
3. Nature of substances secreted by liver
which are essential for nervous centres,
476.

Renault, J., Schick teat for susceptibility to
diphtheria, 26.

Renaux, E., homogenization of tuberculous
sputa and search for T.B. in cold ab-
scesses, suppurative glands, and urines,
559.

Renon, L., et Mignot, R., epidemiology of in-
fluenza, 295.

Rensch, 0. B. : see Corper, H. J.,andRensch,
0. B.

Rettger, L. F. : see Cheplin, H. A., and
Rettger, L. F.

Rey, J. F., dysentery due to Morgan's No. 1 or
No. 14 bacillus, 402.

Reyn, A. : see Chievitz, 0., Jensen, J., Reyn,
A., and Collin, E.

7{ibadeau-Dumas, Mallet, et de Laulerie,
radiological examination of kidneys after
intraperitoneal insufflation, 286.

Ribierre, P., et L^obardy, J. de, gonococcal
septicaemia, 211.

Richard, L., size of spleen in abdominal
cancer, 120.

Richards, J. H., bacteriologic studies in
chronic arthritis and chorea. Part I.
Arthritis, 70.

Riche, general analgesia by intrathecal in-
jections of novocaine, 523.

Richter, H., essential lesion of tabes, 547.

Richter, S., analysis of 601 cases of lumbar

anaesthesia, 521.
Richter-Quittner, M. : see Falta, W., u.

Richter-Quittner, M.
Rick, F., paravertebral injections in gynaeco-
logical cases, 523.
Riemschneider, G. , diphtheritic paralysis of

central origin, 24.
Rieux et Zoller, Shick test of susceptibility to
diphtheria, 26.

Rist, E., et Strohl, A., experimental and
critical studies on pneumothorax, 570.

Ritter, I. S. : see Stern, M., and Ritter, I. S.

Rivers, T. M., ligation of common carotid for
haemorrhage into a post-scarlatinal
abscess, 325.

Rivers, W. H. R., protopathic sensibility,
142.
see Head, H., Rivers, W. H. R., and
Sherren, J.

Rixon, C. H. L., and Matthew, D., anxiety
hysteria, 349.

Roberts, D. : see Cole, L. G., and Roberts, D.

Robinson, G. H. : see Meader, P. D., and
Robinson, G. H.

Robinson, G. H., and Meader, P. D., pre-
cipitin test for gonorrhoea, 213.

Rocci, X-ray therapv with now apparatus
giving 200,000 volts, 287.

Rochaix : see Cluzet, Rochaix, et Kofman.

Rockwell, G. E., and McKhann, C. F., growth
of gonococcus in various gaseous environ-
ments, 256.

Roederer, J. : see Adrian, C, et Roederer, J.

Roger, H., winter incidence of epidemic
encephalitis and seasonal recurrence of
chronic forms, 57.

Rohde, K., pancreatic necrosis, 510.

Rolf, I. P. : see Levene, P. A., and Rolf, I. P.

Rolleston, H., change of type in congenital
syphilis, 410.

Rolleston, J. D.," diphtheritic hemiplegia,
24.

Rolleston, J. D., and Macleod, C, intra-
muscular route for injection of diph-
theria antitoxin, 28.

Rona, P., u. Petow, H., poisonous effect of
thiodiglycol upon urease, 179.

Rosen, I. : see Fordyce, J. A., and Rosen, I.

Rosenbloom, J., occupation and bronchial
asthma, 310.

Rosenmann, M., on fibrinolysis, 282.

Rosier, 0. A., gastric ulcer due to plumbism,
5.

Ross, E. L., and Davis, L. H., difference
between the mechanism of hyper-
glycaemia production by ether and by
chloroform, 274,

Rosson, F. B. : see Du Bray, E. S., andRosson,
F. B.

Rothfeld, J., Freund, J., u. Hornowski, J.,
experimental investigations on patho-
genesis and disseminated sclerosis, 347.

Rothlin, E., experimental studies of properties
of surviving vessels under treatment with
chemical stimuli, 378.

Roussy, G., thyroid lesions in Graves's
disease, 247.

Routh, A., spirillolysis caused by chronic
ferments, 407.

Roux : see Duval, P., Roux, et Beclere, H.

Rowland, C. C. : see Mackie, T. J., and Row-
land, C. C.

Rowntree, L. , Chesney, A. M., and Marshall,
E. K., functional capacity of liver, 542.

Roy, M. P. L. J., radium treatment of cancer

of cei-vix uteri, 584.
Rule, F. D. : see Peters, J. P., Barr, D. P.,
and Rule, F. D.

XXXVIU

II. INDEX OF AUTHORS

Bundle, G. W., results of antenatal treatment
of syphilis, 413.

Rusca, C. L., Gaucher's disease, 170.

Russ, S., some problems in biological action
of radiations, 185.

Russell, B. R. G., and Wogiom, W. H.,
respiratory exchange of surviving mou^e
tissues, normal and neoplastic, 68.

Russell, T. H., abdominal symptoms in in-
fluenza simulating an acute surgical
lesion, 300.

Rutherford, A. : see Cranston Low, R., Logan,
W. R., and Rutherford, A.

Ruysch, W. P., typhus in Holland, 192.

V. Saar, G. F., u. Schamberger, R., treatment
of acute suppuration of wrist, 236.

Sabouraud, R., alopecia areata an abortive
form of congenital syphilis, 113.

Sachs, B., intraspinal treatment of neuro-
syphilis with salvarsanized serum, 338.

Sachs, E., and Malone, J. Y., alterations in
brain volume of human subject by in-
jections of hypei-tonic salt solutions,
536.

Salanier, M. : see Natter, A., et Salanier, M.

Salimbeni, d'Herelle's bacteriophage, 74.

Saloz, C. : see Cottin, E., Cramer, A., et
Saloz, C.

Salvesen, H. : see Palmer, W. W., Salvesen,
H., and Jackson, H.

Salvioli, G., histopathology of leprosy, 372.

Sampietro, G., sero-diagnostic studies on
typhus, 170.

Sanborn, G. P., treatment of influenza by
serum of convalescents, 305.

Sanfelice, F., changes shown by acid-resisting
bacilli on passing through animal organ-
ism, 452.

Sanger u. Bornstein, electromyogram in
amyotrophic lateral sclerosis, 533.

Sangiorgi, G. : see Fontana, A., e Sangiorgi, G.

Sappington, S. W., Gaucher's disease, 119.

Satani, Y,, extra-mammary Paget's disease
treated surgically, 114.

Sauer, L. W. : see Mattill, P. M., Mayer, K.,
and Sauer L. W.

Sauve : see Chaton et Sauve.

Savatard, L., early diagnosis of epithelioma
of skin, 114.
leiomyoma of smooth muscle-cells of
arrectores pill, 114.

Saxl, P. : see Brunn, F., Hitzenberger, K., u.
Saxl, P.

Saxtorph, S. M., influenza and tuberculosis,
302.

Schaefer, 0. G. : see Dutiker, R. A., Eckles,
C. H., Dahle, C. H., Mead, S. W., and
Schaefer, 0. G.

Schaeffer, F., and Chotzen, T., radiotherapy
of tumours of hypophysis and of acro-
megaly, 582.

Schaffer, K., intramedullary bifurcation of
posterior root fibres in man, 549.
histopathology of tabes, 547.

Schamberger, R. : see v. Saar, G. F., u.
Schamberger, R.

Schapiro, L., effects of treatment of ankylo-
stomiasis in N. Queensland, 106.

Schaps, Th., danger of cocaine injections,
519.

Schemmel, E., treatment of injuries to
vertebral artery, 332.

Schenk, P., action of histamin on man, 580.
pituitary opotherapy of diabetes, 507.

Scheven : see Lehmann u. Scheven.

Schiassi, B., Graves's disease, 341.

Schick, B,, breaking down of maternal blood
as cause of icterus neonatorum, 580.

Schiffner, O. : see Jagic, N., u. Schiffner, 0.

Schlagenhaufer, F., disappearance of vertebral
bodies (osteolysis), 372.

Schlecht, deep radiotherapy in internal
medicine, 487.

Schmerz, H., sacral anaesthesia, 525.

Schlomovitz, B. H., further experiments on
effects of warming and cooling sino-
auricular node in mammalian heart.
Depth of anaesthesia, tachyonrdia, flutter,
sino-auricular heart-block. (B) Experi-
mental production of ventricular fibrilla-
tion by localized warming of cardiac
tissue, 472.

Schmidt, v., sarcoma following radium treat-
ment of epithelioma of tongue, 583.
100 cases of paralysis of recurrent laryngeal
nerve, 254.

Schmidtmann, M. : seeBrahn,B., u. Schmidt-
mann, M.

Schmieden, V., kinking of bile-duct, 128.

Schmiegelow, E., fatal haemorrhage following
removal of adenoids, 328.

Schmiesing, T., digestion of infants' foods,
387.

Schmilinsky, gastric operations under
splanchnic anaesthesia, 524.

Schnabel, A. : see Doerr, R., Schnabel, A., u.
Vochting, K.

Schneider, K C, and Truesdell, D., study of
low oxygen effects during rebreathing,
382.

Schoemaker, J., pericolitis membranacea,
226.

Schonfelder, T., diphtheria of umbilicus, 20.

Schou, H. J., nerve lesions in early syphilis
and tlieir treatment, 61.

Schultz, 0. T. : see Anderson, R. A., and
Schultz, O. T.

Schulz, W., course of creatinin excretion in
urine in man, with especial reference to
effect of exercise, 180.
Schiitze, H., haemagglutination and its
medico-legal bearing, with observations
upon the theory of isoagglutinins, 163.

Schwalbach, G., aneurysm of vertebral artery,
333.

Schwarz, H. : seeWessler,H., and Schwarz, H.

Schweinburg, E., epidemic of typhus among
German prisoners in Orenburg (Russia)
in 1915, 193.

Scott, E. L., sugar in blood of dog-fish and
sand-shark, 471.

Scott, E. L., and Honeywell, H. E., study of
sugar in blood of normal pigeons, 472.

Scott, E. L., and Kleitmann, N., sugar in
blood of common frog, 471.

II. INDEX OF AUTHORS

XXXIX

Scruton. W. A., hemiplegia occurring im-
mediately after tonsillectomy, 327.
Sebilleau, P., death caused by removal of

tonsils, 327.
Seelig, M. G., cholecystectomy, 129.
Segagni, S., pseudo-a^cites in children, 13.
SC'guin, P., beneficial effect of certain bacteria

in cultivation of buccal spirochaetes,

270.
Semelaigne, G. : see Dufour, H., Semelaigne,

G., et Ravina. A.
Sencert, L. : see Nageotte, J., et Sencert, L.
Senevet, G. : see Lapin, J., et Senevet, G.
Sessa, P., study of gall-stones by X-rays, 92.
Sevestre : see Houzel et Sevestre.
Seyfarth, C, arteriovenous aneurysm between

carotid artery and cavernous sinus,

425.
Sharp, W. B. : see Jordan, E. 0., and Sharp,

W. B.
Shattock, S. G. : see Nitch, C. A. K., and

Shattock, S. G.
Shaw, W. F., and Burrows, A., Wertheim's

hysterectomy for advanced carcinoma of

cervix made possible by use of radium,

5S4.
Shearer, C, amount of heat liberated by

Bacillus coli when grown in presence of

free amino-acids, 567.
Shellshear, J. L., basal arteries of forebrain,

and their functional significance, 348.
Sherren, J. : see Head, H., Rivers, W. H. R.,

and Sherren, J.
Sherrill. J. W. : see Allen, F. M., Mitchell,

J. W., and Sherrill, J. W.
Sherrington, C. S., integrative action of

nervous system, 145.
nature of tonic contraction of muscle,

532.
scratch reflex in spinal cat, 429.
Shiplev. P. G. : see McCollum. E. V., Parsons,

H.' T., Shipley, P. G., and Park, E. A.
von Sholly, A. I., and Park, W. H., report on

prophylactic vaccination of 1,536 persons

against acute respiratory diseases, 1919-

20, 267.
Shorten, J. A., and Ray, C. B., antiscorbutic

and anti-beri-beri properties of certain

sun-dried vegetables, 574.
Sicard, J. : see Bonnet, E., et Sicard, J.
Simmonds, N. : see McCollum, E. V., Sim-

monds, N., Parsons, H. T., Shipley, P. G.,

and Park, E. A.
Simmons, J. S., diphtheria caught from cat,

18.
Simmons, J. S., Wearn, J. T., and Williams,

0. B., diphtheria infections with particu-
lar reference to carriers and to wound

infections with B. diphlhet-iae, 454.
Singer, G., gastro- intestinal haemorrhage in

polycythaemia hypertonica and syphilitic

aortitis, 11.
Sippel, P., congenital torticollis, 132.
Skajaa, K., pathological-anatomical and

bacteriological study of influenza and

influenzal pneumonia, 562.
Skramlik, E. : see Hahn, M., u. Skramlik, E.
Slemons, J. M., analysis of blood in eclampsia,

538, 540.

Sloboziano : see Constantinesco, C. D., et

Sloboziano.
van Slyke, D. D., carbon dioxide carriers of

the blood, 379.
see Palmer, W. , and van Slyke, D.
see Losee, J. R., and van Slyke, D.
Smillie, W. G., beta naphthol in treatment

of hookworm infection, 107.
Smith, C. A. : see Hawk, P. B , Smith, C. A.,

and Bergeim, 0.
Smith, E. B., splenectomy for splenomegalic

cirrhosis, 124.
Smith, J. D., and Wilson, M. A., comparison

of smear, culture and complement fixa-
tion in chronic gonorrhoea in women,

157.
Smith, J. W., results of operations for atony

and prolapse of large intestine, 223.
Snell, M. , umbilical diphtheria, 22.
von Sohlern, gastro-intestinal haemorrhage,

11.
Sorensen, microscopic examination of organs

from cases of influenza, 264.
Sorrel, Etienne, infantile deforming osteo-
chondritis of upper epiphysis of femur,

39.
Soucek, A., vaccination in Bavaria, 205.
Speed, K. , carcinoma of pancreas, 512.
Spencer, W. G., arterial haemorrhage from

ear and its control by ligature of common

carotid, 326.
injury to vertebral artery, 332.
Spencer, W. G., and Horsley, V., connexions

of internal carotid in monkeys, 323.
Spencer, W. G., and Keith, A., melanin

chromatophores in submucous tissue of

caecum and colon, 228.
Spiethoff, B,, sources of error in treatment

by salvarsan, 158.
Spiller, W. G., treatment of spastic gait by

permanent flexion of great toe, 548.
Spolverini, L., vaccine treatment of whoop-
ing-cough, 204.
Spriggs, E. I., duodenal diverticula, 183.
Stark, H. S., obesity and diabetes, 504.
Starling, E. H. : see Kaya, A., and Starling,

E. H.
Starlinger, rate of sedimentation of red cells

during pregnancy, 543.
Stearns, G., and Lewis, H. B., diet and

sex as factors in creatinuria of man,

469. •

Steenbock, H. : see Hart, E. B., Steenbock, H.,

and Ellis, N. R.
Steffen, G. I. : see Cecil, R. L., and Steffen,

G.I.
Stein, R. 0., differential diagnosis between

large- and small-spored ringworm, 112.
Stengel, A., association of glycosuria with

infectious diseases, 497.
Stephenson, M., differentiation of yellow

plant pigments from fat-soluble vitamine,

84.
Stepp, W., and Feulgen, R., identification of

aldehyde-like substance in diabetic urine

as acetaldehyde, 576.
Stern, A., herpes febrilis, 112.
Stern, M., and Ritter, I. S., intravenous in-
jections of sodium iodide in treatment of

II. INDEX OF AUTHORS

gonorrhoea! arthritis, epididymitis, and

prostatitis, 214.
Stertz, G., organization of extrapyramidal

motor system and selective incidence of

paralyses of pyi-amidal origin, 443.
Stettner, E. : see Jamin, F., u. Stettner, E.
Stevens, W. E., and Heppner, M., occurrence

and treatment of chronic gonorrhoea in

women, 214.
Stevenson, G. S. : see Ebaugh, F. G., and

Stevenson, G. S.
Stewart, G. N., and Ragoff, J. M., post-opera-
tive depletion and epinephrin store of

adrenals, 476.
Stillman, E. G., and Bourn, J. M., biological

study of haemophilic bacilli, 154.
Stoichitia, I., blood in influenza, 297.
Stokes, A., and Bigger, J. W., dysentery

epidemic in Dublin, 1919, 399.
Stolkind, E. J., congenital syphilitic aortitis,

410.
Storm van Leeuwen, W., and Zeijdner, J.,

influence of colloids on action of non-
colloidal drugs, 282.
Stoyanovitch, M. D., gas cysts of intestine,

11.
Strandberg, J., et Hedenius, J., chronic

gonorrhoeal arthritis complicated by

keratodermia blenorrhagica. 212.
Strassberg, M., influenza in syphilitic women,

303.
Straub, H., u. Meier, K., blood gas studies.

VIII. Influence of certain digitalis bodies

on permeability to ions of human red

blood corpuscles, 174.
Strauss, E., composition of keratin, 110.
Strauss, H., diagnosis of duodenal ulcer, 6.
Strauss, 0., radiotherapy and polycythaemia,

390.
Strauss, R., gastric cancer, 7.
Strickler, A., and Goldberg, J. M., anaphy-
lactic food reactions and eczema, 110.
Stroe, A., cerebrospinal fluid in typhus,

195.
Strohl, A. : see Rist, E., et Strohl, A.
Strominger, L., cystitis after typhus, 196.
Strouse, S., renal glycosuria, 503.
Sturm, E. : see Murphy, J. B., Nakahara, W.,

Sturm, E.
see Murphy, J. B., Nakahara, W., Hussey,

R. G., Sturm, E.
Suitsu, N., alkaline reserve of blood of insane,

277.
Sullivan, M., and Dawson, P. R.,sulphocyan-

ate content of saliva and urine in pellagra,

283.
Sundstroem, E. S., and Bloor, W. R.,

physiological effects of short exposures to

low pressure, 174.
Sundt, H., malum coxae Calve-Legg-Perthes,

39.

gastric secretions

Sutherland, G. F.

starvation, 473.
response of stomach glands to gastrin before

and shortly after birth, 474.
Swanbeck, C. E. : see Karsner, H. T., and

Swanbeck, C. E.
Symes, J. 0., pancreatic calculi, 513.

Tallo, F., aotion in vitro of neosalvarsan on
B. anthracis from cultures (without cap-
sule) and from the animal organism
(with capsule), 458.

Taniguchi, T., Sachs-Georgi syphilis reaction
and its relation to Wassermann reaction,
362.

Taylor, J., colectomy, 223.

Taylor- Jones, E., action of induction coils,
181.

Teague, 0., and Deibert, 0., diagnosis of
chancroid, 219.

Ten Horn, plication of caecum in treatment
of constipation, 227.

Tewksbury, W. D., pulmonary abscess, 314,
315.

Thewlis, M. W., gargling with chloral hy-
drate solution in treatment of influenza,
305.
influenza in old age, 303.

Thibierge, G., lichen planus distinct from
lichen simplex, 111.

ThJ0tta, Th., studies on bacterial nutrition.
I. Growth of Bacillus influenzae, in haemo-
globin-free media, 502.

Thjt»tta, T., and Avery, 0. T., growth accessory
substances in nutrition of bacteria,
387.

Thomson, 0., and Christensen, S., types of
pneumococci, 73.

Thomsen, O., and Vollmond, E., an attempt
to classify gonococci according to type,
157.

Thomsen, 0., u. Wulfif, F., certain problems
concerning meningococcal infection,
258.
experimental studies of mode of action
of antimeningococcal serum, 63.

Thormiilen, J., melanogen in urine of woman
suffering from melanotic cancer, 229.

Tibaldi, E., on a new species of parasitic
amoeba occurring in crypts of tonsils
{Entamoeba macrohyaUna), 457.

Tichy, H., results of treatment of cancer of
breast by excision and radiation, 421.

Tisdall, F. F., estimation of phenolic sub-
stances in urine, 86.

Tocunaga, H., biology of influenza bacillus,
58.

Tomkinson, J. G., X-rays in treatment of
oriental sore, 114.

Tonnet, J. : see Loeper, M., Forestier, J., et
Tonne t, J.

Torraca, L., lesions of nerve-cells of parietal
plexuses of gastro-enteric canal in conse-
quence of surgical interventions, 371.

Torraca, T., on epithelioma adenoides cysti-
cum(Brooke)ortricho-epithelioma papil-
losum multiplex (Jarisch), 464.

Trask, J. D. : see Blake, F. G., and Trask,
J. D.
in Trendelenburg, P., u. Groebel, W., relation

between parathyroid tetany and calcium
deficit in blood, 278.
Trenkel, H., value of Wildbolz's auto-urine
reaction in demonstration of active tuber-

culosis, 559.

Treupel, G., chronic lung disease following
influenza, 297.

II. INDEX OF AUTHORS

xli

Treupc'l u. Kayser-Peter.sen, inimuuityagainst
influenza, 304.

Trcindle, A., new experiments on uptake of
substances by cell, 478.

Trotter. W., on certain clinically obscure ma-
lignant tumours of nasopharyngeal wall,
242.
pathological physiology of the skull, 428.

Trotter, W., and Morriston Davies, H.,
results of experimental nerve section in
man, 4G.

Truesdell, D. : see Schneider, E. C, and
Truesdell, D.

Tuffier, cancer of oesophagus treated by direct
application of tube of radium emanation
to oesophageal wall through transpleural
channel, 284.

Tuohy, E. L., splenomegaly with polymor-
phonuclear neutrophil hvperleucocytosis,
121.

TurnbuU, H. M., glycogenic jnfilti-ation of
liver of laboratory rabbits, 67.

Turner, C. G., discoloration of abdominal
wall as sign of acute pancreatitis, 514.

Turretini, G., et Gerber, I., gastric cancer, 8.

Twort, F. W., researches on dysentery, 57.

Udaondo, C. B., y Carulla, J. E., syphilis of

pancreas, 512.
Uhlenhuth, E., experimental production of

gigantism by feeding anterior lobe of

hypophysis and pituitary gland, 179.
V. Uji, S., intestinal obstruction caused by

ascarides, 104.
Umber, F., diabetes and pregnane}-, 501.
Unger, L. J. : see Hess, A. F., and Unger,

L. J.
Unneberg, A. : see Williams, A. W., Unne-

berg, A., Goldman, A., and Hussey, H.
Urbantschitsch, E., case ' of influenza with

bilateral choked disc and unilateral

paralysis of 6th nerve, 300.

Vaccarezza, R. F., y Finochietto, R., case of
acute amoebic dysenterj', 402.

Vallardi, C, epidemiological and clinical
notes on protozoan dysenteiy, 456.
dysentery epidemic in Macedonia, 1918,

399, 456.
mixed dysenteric forms, 456.
sero-diagnosis in bacillary dysenteric in-
fections, 456.

Vandenbosche, instant death during removal
of tonsils, 327.

Varo, B., effect of the war on incidence and
mortality of eclampsia, 542.

Vaudremer, hypopyon complicating typhus,
196.
treatment of typhus, 198.

Vaudremer, A., facultative acid fastness in
tubercle bacilli, human and bovine,
260.

Vaurs, R., perforation of stomach in gastric
cancer, 8.

Vernon, H. M., apnoea after forced respira-
tion, 432.

Viannay, C, injui\v causing spasmodic con-
traction of arteries, 33, 34.

Vicente, M., bile enemata in treatment of
constipation, 15.
see Bensaude, R., et Vicente, M.

Viets, H., relation of form of knee-jerk and
patellar clonus to muscle tonus, 54.

Vigevani , G., pituitary opotherapy of diabetes,
507.

Vigno, P. : see Civatte, A., et Vigne, P.

Vines, H. W. C., role of calcium in coagula-
tion of blood, 558.

Vochting, K. : see Doerr, R., Schnabel, A., u.
Viichting, K.

Vogel, C, tuberculosis cutis vegetans, 112.

Vogt, H., dysentery in children during epi-
demic at Barmen, 1899-1901, 400.

Vollmond, E. : see Thomson, 0., and VoU-
mond. E.

Volpino, G., e Desderi, P., microscopic ob-
servations on brains from some cases of
epidemic encephalitis, 452.

Vorschiitz, J., investigation on agglutination
and sedimentation of bacteria, 176.

Wagener, H. P., and Wilder, R. M., retinitis

in diabetics, 499.
Wagner, K., complications of vaccination,

208.
Waite, J. H., and Neilson, I. L., ankj'losto-

miasis in N. Queensland, 106.
Walker, I. C, hay fever, 309.

fibrinous bronchitis, 312.
Wallgren, A., acute leukaemia in pregnancy:

an argument against theory of infectious

origin of disease, 64.
Wallis, R. L. M., tests for functional activity

of pancreas, 514.
Walshe, F. M. R., conditions of extensor

muscles in spastic paralysis, 533.
relationship between muscle tone and

tendon reflexes, 532.
Walterhofer, G. , action of X-rays in leukaemia,

486.
Warburg, , u. Negelein, E., oxidation of

cystin and other amino-acids by blood

charcoal, 480.
Ward, E., urticaria following acute fevers,

113.
Wassermann, S., skin pigmentation in

soldiers, 112.
Watson, A. : see Paton. D. N., and Watson, A.,

574.
Waugh, G. E., surgical treatment of mobile

caecum and ascending colon, 227.
Wearn, J. T. : see Simmons, J. S., Wearn,

J. T., and Williams, 0. B.
Webster, L. T, : see Lewis, W. H., and Webster,

L. T.
Weed, L. , and McKibben, P., experimental

production of alterations in cerebrospinal

fluid pressure and brain volume, 535.
Weichbrodt, R., intraspinal treatment of

neurosyphilis, 339.
Weil, M. P., cystic pneumatosis of intestine,

11.
Weil, P. E., Wassermann reaction in chronic

splenomegaly, 121.

xlii

II. INDEX OF AUTHORS

Weil, P. E., et Plichet, diabetes and hirsuties,
502.

"Weill, E., et Dufourt, A., intramuscular
injection of ether in treatment of whoop-
ing-cough, 202.

Weill-Halle, B., intramuscular route for
injection of diphtheria antitoxin, 28.

Weinberg, J. A., influence of exposure to
X-rays on growth of tuberculosis, 395.

Weinberg, M., et Kepinow, L., leuco-
agglutinins, 461.

Weinberg, M., et Otelesco, I., B. proieus of war
wounds, 451.

Weiss, H., heat resistance of spores, with
special reference to spores of B. botulinus,
352.

Weiss, M., analysis of colouring substances of
urine. II. Urochromogen, 282.

Weiss, W., salvarsan in treatment of pul-
monary gangrene, 316.

Wertheim Salomonson, J. K. A., electro-
myogram in tendon reflexes, 531,
electromyogram in nervous diseases, 533.

Wessler, H., pulmonary abscess, 314.

Wessler, H., and Schwarz, H., pulmonary
abscess, 315.

Westergren, A., suspension stability of blood
in pulmonary tuberculosis, 366.

Westphal, A., unusual motor symptoms in
disseminated sclerosis, with reference to
differential diagnosis from epidemic
encephalitis, 248.

White, C, sodium bicarbonate tolerance in
normal and toxaemic pregnancies, 539.

White, C. J., anaphylactic food reactions and
eczema, 111.

White, H. L., and Erlanger, J., effect on
composition of blood of maintaining an
increased blood-volume by intravenous
injection of gum acacia in normal,
asphyxiated, and shocked dogs, 273.

Widal, F., et May, E., gonococcal septicaemia
complicated with icterus, 211.

Widal, P., Abrami, P., et lancoresco, N.,
effect of glucose on white blood count of
diabetics, 498.

Wiener, H. J. : see Mosenthal, H. 0., and
Wiener, H. J.

Wieting, wound diphtheria, 23.

Wilder, R. M. : see Wagener, H. P., and
Wilder, R. M.

Wildhagen, K., primary round-celled sarcoma
of lung, 317.

Wile, U. J., syphilis of pancreas, 511.

Williams, A. W. : see Park, W. H., Williams,
A. W., and Krumwiede, C.

Williams, A. W., Kevin, M., Gurley, C. R.,
methods of demonstrating micro-
organisms including ' filtrable viruses '
from upper respiratory tract in ' health '
in 'common colds', and in 'influenza',
with the object of discovering ' common
strains', 267.

Williams, A. W., Unneberg, A., Goldman, A.,
and Hussey, H. , relationship to upper
respiratory infections of streptococci
producing a green zone on standard
blood-agar plates (Smith and Brown's
alpha type), 267.

Williams, J, W,, causation of foetal deaths,
407,
value of Wassermann reaction in pregnancy,
409.

Williams, 0. B. : see Simmons, J. S., Wearn,
J. T., and Williams, 0. B.

Williamson, R. T., dietetic treatment of
diabetes, 505.

van der Willigeu, A. M. M., purgative action
of sulphur — of calomel — of phenol-
phthalein, 180.

Wilson, C. M. : see Pannett, C. A., and
Wilson, C. M.

Wilson, D, W., pyrimidine metabolism, 89,

Wilson, G. H. : see Browning, C. H., and
Wilson, G. H.

Wilson, M. A. : see Smith, J. D., and Wilson,
M. A.

Wilson, S. A, K., on decerebrate rigiditj' in
man and occurrence of tonic fits, 55.

Wishart, M. B., experiments on carbohydrate
metabolism and diabetes. III. Per-
meability of blood corpuscles to sugar,
86.
see Allen, F. M., and Wishart, M. B.

Wishart, M. B., and Pritchett, I. W., experi-
mental studies in diabetes : gas bacillus
infections in diabetic dogs, 273, 275.

With, C, effects of light baths on vitiligo,
111.

De Witt, L, M., mercury compounds in
chemotherapy of experimental tuber-
culosis in guinea-pigs, 262.
weight curves of tuberculous guinea-pigs,
82.

Witzemann, E. J., disodiumphosphate as
a catalyst for quantitative oxidation of
glucose to carbon dioxide with hydrogen
peroxide, 178.

Woglom, W. H. : see Russell, B. R. G., and
Woglom, W. H.

Wolf, C. G. L., influence of reaction of media
and of presence of buffer salts on meta-
bolism of bacteria, 66.
see Ewing, J., and Wolf, C. G. L.

Wolff, E. : see Neuberg, C, Nord, F. F., u.
Wolff, E.

Wollman, E., d'Herelle's phenomenon, trans-
missible microbic autolysis of Bordet
and Ciuca, and Darwin's theory of pan-
genesis, 74.

Woloshin, B., treatment of bronchial asthma
by hypodermic injection of benzyl ben-
zoate, 312.

Wood, F. M., treatment of diphtheria by
injectingdevitalizedKlebs-Loeffler bacilli
and antitoxin, 30.

Woodman, H. E., comparative investigation
of corresponding proteins of cow and ox
serum, cow's colostrum and cow's milk
by method of protein racemization,
575,

Worner, E. : see Moog, 0., u. Worner, E.

Wright, A. E., ' intertraction ' between
albuminous substances and saline
solutions, 577.

Wu, H. : see Aub, .J. C, Cunningham, T. D.,
and Wu, H.

Wulff, F. : see Thom&en, 0., u. Wulff, F.

II. INDEX OF AUTHORS

xliii

Wulff, P., aneurysm of internal carotid after

tonsillar abscess, 325.
Wuth, G., biological effect of proteinogenous

amines. A contribution to question of

acetonitrile reaction, 578.

Yamane, Jinshin, physical and chemical
properties of horse semen in relation to
physiology of spermatozoa, 477.

Young, J., and Miller, D. A., eclampsia due
to absorption of toxic products from
degenerated portions of placenta, 544.

Young, M. L., amoebic dysentery in London
Children's Hospital, 400.

Zanelli, P., action of continuous electric
current on agglutinating sera, 355.

Zappa, P., on normal leucocytic formula,
169.

Zeijdner, J. : see Storm van Leeuwen, W., and
Zeijdner, J.

Zeller, H. : see Herzog, F., u. Zeller, H.
Zenoni, C, e Macchi, A., pulmonary strepto-

thricosis, 316.
Zielinski, C, treatment of typhus by intra-
venous injection of patient's cerebrospinal

fluid, 198.
Zilva, S. S., action of ozone on fat-soluble

factor in fats, 85.
see Drummond, J. C, Goldin2, .J., Zilva,

S. S., and Coward, K. H.
Zlocisti, T., typhus in German Red Cross

Hospital at Constantinople, 193.
Zoeller : see De Lavergne et Zoeller.
Zoepffel, H. : see Neumann, J., \i. Zoepffel, H.
Zondek, S. G., importanceof colloidal nutrient

solutions for normal, exhausted, and

poisoned heart., 576.
Zweifel, E., sacral anaesthesia, deaths from,

525.
theories as to cause of eclampsia, 537, 544.
Zoller : see Rieux et Zoller.

PRINTED AT OXFORD, ENGLAND

BY FREDERICK HALL
PRINTER TO THE UNIVERSITV

MEDICAL SCIENCE

ABSTRACTS & REVIEWS

Volume IV. Number 1 April 1921

CONTENTS

REVIEWS : page

ALIMENTARY DISEASES 3

DIPHTHERIA 18

INJURY CAUSING SPASMODIC CONTRACTION OF SEGMENTS OF

ARTERIES OF MEDIUM SIZE 33

NON-TUBERCULOUS JUVENILE COXALGIA 38

ANTERIOR DISLOCATION AT THE ELBOW 41

THE PHYSIOLOGY OF PAIN 43

ABSTRACTS :

SURGERY ^2

NEUROLOGY ^3

PATHOLOGY AND BACTERIOLOGY 57

BIOCHEMISTRY .^*

RADIOLOGY AND ELECTROLOGY 91

MEDICAL RESEARCH COUNCIL

The viscount GOSCHEN, C.B.E. {Chairman)

WILLIAM GEAHAM, M.P.

The Hon. EDWAKD F. L. WOOD, M.P. {Treasurer)

C. J. BOND, C.M.G., F.Pt.C.S.

Professor WILLIAM BULLOCH, M.D., LL.D., F.E.S.

T. R ELLIOTT, C.B.E., D.S.O., M.D., F.R.S.

HENEY HEAD, M.D., F.E.S.

Professor F. G. HOPKINS, D.Sc, F.E.C.P., F.E.S.

Major-General SIE WILLIAM LEISHMAN, K.C.M.G., C.B., F.R.S.

Professor NOEL PATON, M.D., F.E.S.

SIE WALTEE M. FLETCHEE, K.B.E., M.D., Sc.D., F.E.S. {Secretary).

The Council are indebted to the following for editorial superintendence in
the subjects named :

Medicine . . . . J. D. EOLLESTON, M.D.

Surgery . . . . W. G. SPENCEE, M.S., F.E.C.S.

Pathology and Bacteriology W. BULLOCH, M.D., LL.D., F.E.S.

Neurology . . . F. M. E. WALSHE, M.D. F.E.C.P.

Radiology . . . W. S. LAZAEUS-BARLOW, M.D., F.E.C.P.

SIDNEY RUSS, D.Sc.

Biochemistry . . C. G. L. WOLF, M.D.

All communications on editorial matters should be addressed to

E. SCHUSTER, D.Sc,
Assistant Secretary, Medical Research Council,

National Institute for Medical Research,

Hampstead, N.W. 3.

REVIEWS

ALIMENTARY DISEASES

Jardet records four cases of parotid swelling occurring in adults
characterized by sudden enlargement of tlie gland, which almost always
occurred after the first meal of the day and rapidly increased duriiif
mastication, its subsecjuent development depending on whether it was
a primary attack or a relapse, and the character of the food. The swellino-
was accompanied by local tension, restricted movement of the jaw, and some-
times by pain, which was acute for the first half hour and dull afterwards,
as in mumps. Contrary to what occurs in mumps, however, on pressure on
the gland distinct lobulation could be felt, and occasionally a hard cord of the
size of a pencil representing Steno's duct. Pressure on the gland caused
expulsion of a plug of mucus followed by a (low of saliva. The affection
usually starts the first week that a tooth-plate is worn, but it may occur
later. It may last for some days, but usually disappears more or less
completely the same day, and recurs the next and for five or six days in
succession. It then subsides, but returns after an interval of a month or
six weeks as the result of a chill, irritating food, or the onset of menstruation.
The condition is due to the tooth-plate producing irritation of the gum and
obstruction of the orifice of Steno's duct with subsequent retention of saliva.
Cure is effected by removal of the tooth-plate and its careful readjustment,
together with the use of a potassium chlorate mouth-wash.

Gastric analysis. Briining, director of the Rostock University
Children's Clinic, reports the results of about 300 examinations of the
gastric contents in children aged from 2 to 15 years. While the total
normal acidity in adults is 30-(jO and the average free hydrochloric acid is
20-40, the average total acidity in children was found to be 48-8 and the
free hydrochloric acid 14-3. Hardly any differences were noted between
boys and girls, either in the upper or lower classes of society. On the other
hand the figures rose as the age of the child advanced. Thus between 2
and 10 years the total acidity was 46-9 and the free hydrochloric acid 11-5,
and between 11 and 15 the total acidity was 52-8 and the free hydrochloric
acid 20-1. During the war there was almost invariably a diminution of the
hydrochloric acid values, as was found by other writers in adults. On
ranging the children in two groups, according as their digestion was normal
or diseased, it was found that the total acidity and free hydrochloric acid
were higher in normal children than in those suSering from gastro-intestinal
disturbance. There were no less than 63 cases, or 21 per cent., with hypo-
chlorhydria or achlorhydria. It was a remarkable fact that 13 of the cases
of achlorhydria had no gastro-intestinal symptoms, while the rest suft'ered
from abdominal pain, diarrhoea, or constipation.

IV. B 2

4 REVIEWS

As the result of a study of a larg^e number of cases, Rebfuss and Hawk
found that the normal individual elaborates acid figures as high as those
commonly associated with pathological conditions, no acid figures being-
found in disease which exceeded the figures present under certain circum-
stances in health. The average acid finding during the digestion of certain
foods in the normal stomach was found to be within the range which is
accepted by all clinicians as abnormal. It was found that approximately
40 per cent, of normal individuals constantly show the acid titration
findings of so-called hyperacidity.

Dupuy describes the test of sham feeding introduced by Carnot in 1904
as the practical application of Pavlov's well-known experiments. After
preliminary catheterization of the stomach before breakfast to determine if
there is any stasis, in which case the stomach is completely emptied, the
patient is given an appetizing meal of ten minutes' duration, which he is told
to masticate slowly without swallowing, the food and saliva being spat out
after mastication into a special basin. He is then left for ten minutes, and
told not to swallow but to spit out the saliva secreted. At the end of this
time the catheter is passed again, and in normal cases 60-90 c.c. of clear
fluid is withdrawn without any particles of food. The free hydrochloric
acid varies from 1-64 to 1-80 and the total acid from 1-80 to 1-96. In seven
out of eight cases of cancer of the stomach Dupuy found that the total acid
was below 1 and that there was an absence of free hydrochloric acid. In
gastric ulcer the quantity of gastric juice secreted after sham feeding was
normal in the case of ulceration of the body of the stomacli, and generally
increased in active or recently healed prepyloric or pyloric ulcer. In
duodenal ulcer the secretion was usually increased. In dj'spepsia due to
gall-stones there was an excess of secretion and of hydrochloric acid. In
nervous dj'spepsia the secretion might be normal, exaggerated, or defective
in amount and acidity. In tabes the secretion was often entirely absent.

In alcoholism hj^perchlorhj'dria was usually present in the early stage,
but later the amount of hydrochloric acid diminished, falling in extreme
cases as low as 0-365. In tuberculosis with anorexia the quantity of gastric
juice withdrawn after sham feeding was normal, but the fermentative
activity of the gastric juice was still more diminished than its acidity.
Dupuy concludes by saying that 'sham feeding' should be adopted as
a routine method in the examination of gastric chemistry.

Carnot describes the following three forms of plastic linitis according
as the process affects the body of the stomach only or involves the orifices
as well: (1) gastric linitis without involvement of the orifices; (2) cardio-
gastric linitis ; (3) gastro-pyloric linitis. The characteristic features of the
first form are microgastria, rigidity, and thickening of the wall of the
stomach. The symptoms are dysphagia and regurgitation resulting from
the small capacity of the stomach. In cardio-gastric linitis there is
a rigidity of the cardiac orifice which is manifested by stenosis of the
cardiac end of the stomach. The symptoms consist in dysphagia and
regurgitation of mucus and food. The oesophageal bougie is arrested at the
cardiac orifice or even higher up, at least 40 cm. from the teeth. Diagnosis
of a new growth at the cardiac end of the stomach in such cases is therefore
almost inevitable. In gastro-pyloric linitis there is a rigidity of the
pyloric orifice, giving rise to pyloric incontinence which predominates over
pyloric stenosis.

Gastric and duodenal ulcer. In discussing the aetiology of gastric

ALIMENTARY DISEASES 5

and duodenal ulcer, Hurst states that he has seen a number of cases in which
two or more brothers and sisters have suffered from gastric and duodenal
ulcers, and still more in which brothers and sisters of a patient with
a o-astric or duodenal ulcer have had symptoms of a similar character, 1 >ut so
much less severe that it seemed impossible that actual ulceration was present.
In one family the father and two out of nine children were dyspeptic and
four others had typical symptoms of duodenal ulcer, one dying from
a perforation. Hurst has never seen one meml)er of a family with
a gastric ulcer and another with duodenal ulcer. This suggests that the
types of stomach which predispose to the development of gastric and
duodenal ulcer respectively are congenital, and either one or the other may
exist in several members of a family.

Albu also considers that a congenital predisposition to peptic ulcer
exists, and remarks that all experienced practitioners have known families
in which a so-called 'weak stomach' is transmitted from one generation to
another. This condition is often nothing but a latent gastric or duodenal
ulcer. In the pathogenesis of gastric and duodenal ulcer he distinguishes
a series of different factors which include a predominant nervous or vago-
tonic cause, insufficiency of the organs, and various occasional causes.

According to Boas of Berlin, the frequency and severity of chronic
gastric ulcer have recently shown a decided increase, which is manifested
by the frequency of haematemesis, relapses, and perforation. It is natural
to suppose that war diet is chiefly responsible for these complications, but
Boas draws attention to another factor which has not received suflicient
attention, namely, an increased amount of heavy work, particularly in
women living in the country, who in the absence of then' husbands on
military ser\-ice had to undertake work which was out of proportion to
their strength.

Nicolaysen reports ten cases of haemorrhagic erosions of the stomach
or duodenum observed in the course of the last two years at the Rikshospital,
Christiania. In six of the cases irritation of the vagus was produced during
the course of the illness, which in every case was situated in the brain or its
membranes. In a second group of three cases the disease involved the
chest, the lungs and pleura being the seat of infiltrating processes. In the
last case, one of peritonitis with empyema, there may have been involvement
of the nerves of the stomach in the abdomen as well as in the thorax.
Nicolaysen's results show that in most of the cases in which haemorrhagic
erosions were found there had been irritation of the vagus or the possi-
bility of such irritation.

Rosier, of the Graz University Medical Clinic alludes to Schiff's recent
article on the relation of gastric ulcer to plumbism (vide Medical Science,
1920, 1, 584-5) and records a case in which a gastric ulcer developed as
a sequel of a functional spastic hour-glass contraction in a woman aged 25,
the subject of chronic plumbism.

The occurrence of ascites in connexion with duodenal ulcer is an
extremely rare event. Only one example of the kind occurred among 129
cases of duodenal ulcer operated on by Haberer, a little free fluid being
evacuated on laparotomy. Out of 121 cases of duodenal ulcer operated on
by Finsterer, from whose paper this information is taken, in only two was
there a large amount of ascites present. In one of them, however, there
was hepatic cirrhosis, while in the other the liver was quite normal, but
the ascites was due to compression of the portal vein. Complete recovery

6 REVIEWS

followed excision of the ulcer. The fact that duodenal ulcer may give rise
to considerable ascites is of diagnostic and prognostic importance, because
exploratory lapai'otomy which might reveal the true condition might be
declined on the mistaken idea that mahgnant degeneration of the ulcer was
responsible for the ascites.

Brunn, Hitzenberger, and Saxl, recently examined 69 cases of gastric
or duodenal ulcer which had been treated at the First Medical Clinic in
Vienna between 1911 and 1919, and found that in both gastric and duodenal
ulcer there is a period of complete absence of symptoms which alternates
with a period in which symptoms are present. Even in this latent period
objective signs, and especially X-ray changes, can be detected. The writers
therefore conclude that only a xery small number of cases of gastric or
duodenal ulcer can be regarded as cured.

The value of the string test in the diagnosis of peptic ulcers and their
location is illustrated by Einhorn (1). The test is performed as follows:
The duodenal bucket, attached to a thread, a knot in which is made at the
teeth, is swallowed in the evening after supper w^ith a glass of water. In
the morning before breakfast it is slowly withdrawn and the thread is
examined for blood spots and bile stains. The distance of the blood spots from
the knot at the teeth will show the location of the ulcer. Thus a blood-
stain at about 40 cm. (16 in.) points to an ulcer of the cardia ; from 44-54 cm.
(17^-21^ in.), ulcer of the lesser curvature ; from 55-56 cm. (22-2.2f in.), ulcer
of the pylorus ; 57 cm. (22^ in.) and more, duodenal ulcer. Einhorn regards
the thread test as of importance not only in the recognition of the position
of the ulcers, but also as a criterion of the efficiency of treatment, especially
in determining whether a cure has been effected or not.

According to H. Strauss, of Berlin, apart from certain rare X-ray find-
ings, there is no single symptom really pathognomonic of duodenal ulcer.
Since 1911 he has maintained that for practical purposes it is sufficient to
make a diagnosis of parapyloric ulcer, a term which includes all ulcers on
either side of the pylorus as well as in the pylorus itself, and that a diagnosis
of this condition is more frequently correct than the difficult one of duodenal
ulcer. He regards the triad of symptoms — hyperaesthesia, hypersecretion,
and hypermotility as to a certain extent characteristic of the parapyloric
symptom-complex. He considers hypersecretion as more important than
hyperacidity. In his experience two-thirds to three-quarters of all cases of
hypersecretion are due to a parapyloric affection. He points out that
manifest or occult haemorrhages are by no means a necessary symptom of
ulcer, the number of negative blood findings in the faeces varying with
dift'erent writers from 25 to 50 per cent. On the other hand, he regards the
undoubted presence of blood in the faeces as of very great diagnostic
significance.

Dunham maintains that visceral syphilis is frequently responsible for
errors in the diagnosis of duodenal ulcer, and for the last five years has had
a routine Wassermann reaction made on every patient with chronic digestive
disturbance. If signs of syphilis are found after making a diagnosis of
duodenal ulcer, the patient should be given thorough antisyphilitic treat-
ment, even if the Wassermann reaction is negative.

According to Ramond, pyloric spasm is a very frequent affection, but
its symptoms, which are usually attenuated, readily escape notice. In some
cases, however, they are verj?- pronounced. The causes of pyloric spasm may
be local, reflex, or general. The local causes, which are the most numerous

ALIMENTARY DISEASES 7

and important, include gastritis, gastric ptosis, and badly masticated food.
Retlex pyloric spasm is most frequently due to cholelithiasis and appendicitis,
less frequently to renal calculus, pancreatic lithiasis, floating kidney, and
constipation. General causes consist of intoxications, especially tobacco, and
emotions. Two forms of pyloric spasm may be distinguished, viz. an inter-
mittent form, which is much the commonest, and a continuous type. In the
intermittent type the spasm may occur at the beginning of digestion or
later. The patient has a sudden loss of appetite, and gaseous eructations
occur with or without pyrosis and regurgitation of food. Nausea and
vomiting are exceptional. In a few moments the spasm ceases and there is
almost immediate relief. Continuous pyloric spasm, of which Ramond and
Clement report an example, is manifested by continuity of all the above
symptoms, the condition in course of time closely resembling pure pyloric
stenosis with dilatation.

Lichtenstein has come to some unorthodox conclusions concerning
pylorospasm, 24: cases of which were treated at the Sachska Children's
Hospital. These cases represent 1-9 per cent, of all the patients under one
year. There were only 5 females to 19 males, and the numbers of breast-
ted and artificially fed infants were approximately ec^ual. It was noted
that, even in severe and perfectly typical cases, the pylorus might never be
palpable. A palpable pylorus should therefore not be regarded as necessary
to the diagnosis for wliich the triad, tonic vomiting, great loss of weight,
and visible peristalsis of the stomach, are sufficient. [Special interest attaches
to the case of twins, boys, one of whom developed typical pylorospasm at
the age of two weeks, the other at the age of a month. The mortality,
which various authors have put at 20 to 87 per cent., was in Lichtenstein's
material only 4-1 per cent., and his single fatality was associated with
cleft palate, wliich greatly interfered with the infant's feeds. His successes,
achieved by dietetic and other conservative measures, are reflected in his
disparaging discussion of operative treatment. He rejects the common
view that pylorospasm is most frequent among breast-fed infants, and that
artificial feeding is accordingly indicated. As a rule, he prefers small feeds
at short intervals, i.e. 8-12 feeds of 25 to 75 grm., and he found that in
some cases it was better to give human milk artificially, as sucking was apt
to provoke pylorospasm. The two other principles he advocates are (1)
replacement of the fluid lost in vomiting by rectal or subcutaneous injections
of Ringer's solution, and (2) isolation to prevent the patient contracting
influenza or any of the other intercurrent diseases responsible for many of
the fatalities from pylorospasm.

Cancer of the stomach. R. Strauss gives the following statistics of 190
cases of undoubted gastric cancer from the Medical and Surgical University
Clinic at Rostock. The paper, as Curschmann remarks in a footnote,
though not containing anything really new, is of value, owing to its being
based on a large number of cases. 67-6 per cent, of the cases occurred in
men and 32-4 per cent, in women. No case was met with below the age
of 30. 37-7 per cent, occurred between 50 and 60, and 89 per cent, between
40 and 70. According to the histories considerably more than half the cases
were in persons who had previously always had healthy stomachs, their
first symptoms dating back to six months at most and usually only a few
weeks. About one-fifth of the cases had formerly suffered from gastric dis-
turbance or had had their first symptoms two years previously. Examination
of the acid values in 160 cases gave the following results : free hydrochloric

8 REVIEWS

acid was present in about 19 per cent, and absent in 81 per cent. 78-6
per cent, showed hypoacidity, 13-8 per cent, normal acidity, and 7-6 per
cent, hyperacidity, 40-70 being reckoned as normal acidity, below 40 as
hypoacidity, and above 70 as hyperacidity. 9 per cent, showed complete
achlorhydria. 8 per cent, of the cases had developed on an old ulcer, as
was shown by clinical and anatomical examination. As regards the
frequency of the various symptoms, constipation was present in 60 per cent.,
vomiting in 60 per cent., anorexia in 71 per cent., blood in the gastric con-
tents or faeces, including occult haemorrhage, in 64-7 per cent. In 91 per
cent, of the cases which came to operation there was more or less marked
emaciation. A distinctly circumscribed palpable tumour was found in
60 per cent., and a more or less definite resistance in another 21 per cent.,
so that only 19 per cent, of the definite cases of carcinoma showed no
evidence of a tumour on palpation before operation.

Turretini and Gerber record a case of gastric cancer in a woman aired
30 which was remarkable for the fact that it never caused the slightest
pain or vomiting except during a period of jaundice, when vomiting took
place. The only clinical symptoms of the tumour were thrombosis of the
.right innominate and internal jugular veins which gave rise to considerable
oedema of the face and arm, and progressive dyspnoea without any definite
signs in the lungs, which suddenly developed a few days before death. The
autopsy showed carcinoma of the stomach, generalized carcinoma of the
pulmonary lymphatics and lungs, and thrombosis of the superior vena
cava, innominate and internal jugular veins.

A case of cancer of the stomach complicated by chylous ascites is reported
by Hendricks in a man aged 72 who presented enlarged glands on the left
side of the neck a few weeks before death. The necropsy revealed milky
fluid in the abdominal cavity, cancer of the stomach, and metastases in the
liver, lungs, mediastinal glands, and the glands in the left side of the neck.
The thoracic duct was dilated. Hendricks has found that at least 10 per
cent, of the recorded cases of chylous fluid in the thorax or abdominal
cavity or both have been due to malignant disease.

According to Vaurs, who has collected nine cases, including one of his
own, perforation of the stomach is a rare complication of gastric cancer.
It cannot be attributed to a special pathological form of the tumour, but it
appears to be mainly due to the state of nutrition of the neoplastic tissue.
Necrosis of the newly formed elements infiltrating the stomach wall takes
place and a slough is formed which separates and so permits of communica-
tion with the peritoneum, into which the septic contents of the stomach are
discharged. The consequences of the perforation depend upon (a) the point
of the stomach wall where sloughing has occurred, (b) the rapidity witli
which the slough forms, and (c) the more or less marked reaction of the
serous coat. According to the relative importance of the last two factors
there occurs either a localized or a generalized peritonitis, the latter having
all the appearances of an acute septic peritonitis. Massive infection of the
peritoneum results, so that there is little chance of an operation being
successful even if the condition is recognized at once.

From a study of the blood-sugar tolerance test in health as well as in
various aflectionsof the gastro-intestinal tract, Friedenwald and Grove have
found that in gastro-intestinal carcinoma there is a rather characteristic
curve of sugar tolerance which differs somewhat from that observed in
carcinoma of other regions. The curve of this affection usually presents

ALIMENTARY DISEASES 9

a high sugar content, even in the fasting state, followed by an initial rise up
to 0-24 per cent, or higher within 45 minutes after the ingestion of the
dextrose, remaining at this level for at least 120 minutes and at no time
during this period falling below 0-20 per cent. The writers consider that
the sugar tolerance test may render valuable assistance in a large proportion
of eases, as a means of differential diaofnosis between carcinoma and other
diseases of the (rastro-intestiiial tract.

Primary sarcoma of the stomach forms the subject of three important
papers by Koettlitz, Basch, and Haggard respectively. Although Koettlitz
regards the condition as comparatively rare, only 171 cases having been
collected byGosset in 1912, Basch maintains that it is of more frequent
occurrence than individual experience would lead one to infer. 244 authentic
cases have been collected by Hagoard, including one of his own and 13 un-
published cases from the Mayo Clinic. The condition may occur at any age,
the youngest being in a boy aged 3^ years (Finlayson), and the oldest in
a man of 85 (Gosset), but it is most frequent after 40. Of 66 cases in which
the age is stated, 33 were in males and 33 in females.

According to Koettlitz the diagnosis has never been made until operation
or autopsy, except in Westphalen's case, in which microscopical examination
showed the sarcomatous nature of a portion of the vomit. In the majority
of cases the diagnosis has been carcinoma. Gastric sarcoma has also been
mistaken for many other intragastric and extragastric conditions, such as
tumours of the spleen, tuberculous abdominal glands, abscess of the liver,
suppurative peritonitis, pancreatic growth, and benign peptic ulcer with
secondary infiltrating tumour. The symptoms may be so indefinite that the
condition may be attributed to simple dyspepsia, and sometimes there are no
gastric symptoms whatever. This is due, as Basch points out, to the fact
that the mucous membrane is not involved and that usually there are no
obstructive changes. As a rule there are anorexia and gastric pain, and
there is always more or less considerable loss of Hesh. Vomiting occurs in
20 per cent. Haematemesis and melaena are frequent, especially in the
round cell variety, though less so than in carcinoma. Reports as to the
gastric chemistry differ. Whereas Gosset found a complete absence of hydro-
chloric acid, Monti states that hydrochloric acid does not disappear till late.
The only definite symptom is a tumour which was present in 66 out of 72
cases (Ziesche and Davidson). Haggard regards rapid development of anaemia
and debility with loss of weight and cachexia, early rather severe and more or
less persistent pain in the epigastrium, and the absence of any long-standing-
history of dyspepsia and pyloric obstruction, as suggestive of sarcoma. Gastric
sarcoma is generally less malignant than carcinoma. According to Basch, the
average duration of round cell sarcoma, wdiich is the most malignant type, is
about 15 months, that of the spindle cell type 24-32 months, and that of
myxosarcoma 3-| years (see also Medical Science, 1920, 1, 585-6).

According to Du Bray, of the University of California, confirmed cases
of gastric polyposis are comparatively unusual, though he suggests that
some of the vague and obscure conditions of the stomach which have been
diagnosed as chronic gastritis or gastric neurosis might on further examina-
tion prove to be examples of benign tumours of the gastric wall. The term
gastric polyposis includes adenomas, fibromas, lipomas, myomas, and papil-
lomas, which may all form polypoid tumours, in some of which the connective
tissue predominates and in others the glandular elements. Polyadenoma
and papilloma are the most important primary benign tumours of the

10 REVIEWS

stomach, the others being extremely rare. Gastric polyposis is frequently
associated with other morl)id conditions such as gastritis, hypertensive
cardiac disease, and syphilis. It is commonest in men past middle age.
There are no pathognomonic symptoms, although there is sometimes
suggestive evidence of the disease. Clinical manifestations depend
principally on the size, position, and nature of the growth, and especially its
relation to the pyloric end of the stomach. Non- pedunculated masses on
the greater curvature may remain latent or more commonly produce vague
epigastric symptoms followed by a desire to belch and eventually to vomit.
The sj^mptoms do not appear to have any relation to meals. The vomit
contains an excessive amount of mucus, in which sometimes a polyp may
be found, and enable a diagnosis to be made before operation. There is
usually achylia gastrica or hypoacidity^ Pedunculated growths, of which
Novak reports an example, and, less frequently, non-pedunculated growths
near the pylorus may prolapse and give rise to partial or complete pyloric
obstruction. Haemorrhage due to the great vascularity of the growths is
frequent but remains long unrecognized, occult blood being found in the
fasting contents of the stomach and in the stools. The general nutrition,
weight, and blood picture are less affected as a rule than in carcinoma. Long
duration of the symptoms with little or no change in the general health is
strong evidence against the presence of malignant disease, and should
suggest the possibility of a benign tumour.

According to Neuber, three forms of gastric luyomata may be described.
The first, which is situated at the pylorus, is manifested hy symptoms of
pyloric obstruction which may simulate gastric ulcer or carcinoma. The
second form is a subserous myoma which grows outwards into the abdominal
cavity and may be mistaken for an intestinal or omental tumour on the one
hand or for a tumour of the pancreas or retroperitoneal glands on the other.
The third form, of which Neuber reports an example, is a pedunculated
tumour which projects into the cavity of the stomach, where it gives rise to
attacks of cramp and vomiting and is apt to be mistaken for gastric ulcer
or cancer. Clinical examination shows occult haemorrhage and occasionally
a palpable tumour.

Lemon reports a case of angioma of the stomach of which he has found
only five other cases on record. The patient was a medical man aged 67, in
whom the clinical and X-ray diagnosis was carcinoma of the stomach. In
spite of a systolic blood-pressure of 220-240 and an aneurysmal dilatation
of the aorta, an operation was performed and a freely movable tumour, which
proved to be an angioma, was found in the fundus of the stomach. Six
months after removal of the tumour the patient was in good health and
engaged in his medical practice.

Gas cysts of the abdomen. Numerous articles have recently been
published, especially by French writers such as Tufiier and Letulle, De Gery,
Lenormant, Stoyanovitch, Cristol and Porte, and Weil, on the condition
known as gas cysts of the abdomen, intestinal pneumatosis or cystic
pneumatosis of the intestine. In this country Nitch and Shattock have
described two cases under the name of diftuse emphysema of the intestinal
wall. The condition is a rare one, only 70 cases having been recorded
(Weil) since the first human case was reported by Bang in 1876, although
a case in a healthy pig had been published by Mayer in 1825. The affection
consists in the development in the abdominal cavity or peritoneum of gas-
containing cj^sts, which are usually multiple, their size varying from

ALBIENTARY DISEASES 11

microscopical dimensions to that of a hazel nut or a lien's e^g. Their
contents consist of a mixture of carbon dioxide, hydrogen, oxygen, and
nitrogen in varying proportions. Their seat of election is the intestine, but
in some instances tlie alimentary canal is not affected and the cysts are
localized in the mesentery, omentum, or parietal peritoneum. The condition,
which has been found between the ages of 13 and 67, may occur by itself,
but as a rule is associated with a gastric ulcer, especially one which has
reached the cicatricial or stenotic stage. Thus of 54 cases collected \>y Weil,
in 32 there was an ulcer of the gastro-duodenal region which in 72 per cent,
of the cases was stenotic. The other abdominal conditions sometimes
associated with these cysts are intestinal tuberculosis, cancer of the pylorus,
appendicitis, and gastro-enteritis. Owing to the variety of the s^-mptoms,
four forms of the affection have been described by Weil, viz.: (1) a pseudo-
appendicular form in which the symptoms resemble appendicitis, (2)
a peritoneal form simulating tuberculous peritonitis or acute perforative
peritonitis, (3) a form resembling acute or chronic intestinal obstruction as
in the ca.se reported by Cristol and Porte, (4) a form simulating an abdoniiaal
tumour. Owing to the difficulties of diagnosis it is not surprising to learn
that of 57 cases collected by Lenormant, 36 were not discovered till operation
and 21 till autopsy. Weil, however, attaches great diagnostic value to
considerable distension of the abdomen associated with a soft and easily
depressible abdominal wall. Other signs which have been described as
characteristic are a sensation of elastic resistance, peritoneal crepitation,
abdominal transparency on X-ray examination, and the presence of gaseous
ascites. Various theories, according to Stoyanovitch, have been proposed to
explain the formation of the cysts. The mechanical theory that tliey are
due to the passage of the intestinal gas into the subserous tissue is negatived
by the nature of the gas, which resembles atmospheric air, and b}'- the
localization of cysts in other situations than the intestines. The theory
that the cysts are tumours formed at the expense of the lymphatics fails to
explain the presence of gas. The microbial theory, which appears to be the
most probable, is supported by Dupraz, who isolated a liquefying coccus
which on injection into a bitch reproduced the cysts in tlie vagina.

Singer of Vienna, describes two cases of gastro-iutestmal haemorrhage
in polycythaemia hypertonica and syphilitic aortitis respectively, and draws
attention to the fact that various vascular changes associated with high
blood-pressure such as arteriosclerosis and post-syphilitic vascular disease
may lead to severe gastro-intestinal haemorrhage which suggests the
presence of ulceration. He points out that whereas ulcers due to erosion of
large blood-vessels require operation, haemorrhages due to blood and arterial
diseases should be a noli me tangere for the surgeon, and suggests that the
unexplained cases of gastro-intestinal haemorrhage described by Hale White,
Reichard, and others, may be connected with disease of the blood and
vascular system.

Commenting on Singer's paper, von Sohlern of Stuttgart, reports
a case of intestinal haemorrhage in a woman, aged 47, in wliich all the
ordinarj^ causes of haemorrhage could be excluded. He emphasizes the
importance in such cases of making a careful examination of the whole
body, especially of the cardio-vascular system, and not only of the intestinal
tract.

Fritzsche records two fatal cases of primary parenchjaiiatous haemo-
rrhage from the stomach in women aged 38 and 42 respective J}^ for which

12 REVIEWS

no local or general cause could be found either clinically or on post-mortem
examination.

Farnell and Harrinoton record a series of 47 cases of acute infectious
enteritis complicated by polj^neuritis, the cases being classified m three
groups. In the iirst, which consisted of 19 cases, the gastro-intestinal
symptoms were well-marked, and the polyneuritis was also prominent. In
the second group, which consisted of seven cases, the gastro-intestinal
vsymptoms were serious, and in one case fatal, but the neuritic symptoms
were less severe. In the third group, which comprised 21 cases, the gastro-
intestinal disturbance was the principal feature, only a few patients
developing polyneuritis. Bacteriological examination showed that the
condition was due to a virulent, rapidly growing staphylococcus introduced
into the gastro-intestinal tract, this organism being found in the milk,
throat cultures, blood, and urine. Pathologically there were acute haemo-
rrhagic enteritis, multiple focal necroses of infectious origin in the liver, and
acute haeraorrhao-ie neuritis.

Friedman, who reports an illustrative case, classifies cases of non-
specific intestinal infection into three groups, viz. (a) small intestine
catarrhs, (b) diftuse processes involving both small and large intestine, and
(c) colitis. The characteristics of ((() are meteorism, belching, and colicky
jjain, and, especially in involvement of the jejunum and ileum, light brown
or yellowish-brown foaming acid stools with a sour odour. Continuous
diarrhoea with tormina is evidence of type (b), and the stools become
smaller and more numerous as the sigmoid and rectum become irritated.
In type (c), while there may be alternating constipation and diarrhoea, in
the more frequent irritable form there is a stubborn diarrhoea similar to
dysentery, with blood in the stools and often accompanied by fever.

Antoine devotes his Paris thesis to a description of severe forms of
inflammation of the rectum and colon which resemble dj'sentery in their
symptoms and anatomical lesions but difier from it in their aetiology, which
often remains undetermined. In addition to recto-colitis of syphilitic,
tuberculous, uraemic, or toxic nature, there are cases in which examination
of the stools shows various parasites such as lamblia, spirilla, trichomonas,
Balantldium coli, parathyphoid and paradysentery bacilli, and salmonellae.
Clinically the cases may be grouped into haemorrhagic, purulent, and mixed
forms. The gravity of the attack does not appear to be due to the causal
agent or to the anatomical lesions, but to the clinical course of the disease,
which is characterized by repeated and profuse haemorrhage or suppuration,
a protracted course and an absence of any tendency to respond to the usual
treatment. The condition may last for several years with subacute inter-
current exacerbations, and does not fail to give rise to marked loss of flesh,
intense anaemia, and general enfeeblement. The most frequent complication
is a hypertrophic reaction of the intestinal wall giving rise to extensive
stenosis of the large intestine. Complications of an infective nature are less
frequent, such as perforation and peritonitis, high fever, suprarenal in-
competence, joint lesions, or venous thrombosis.

The first section of Bloch's work is an attempt to clear the ground with
regard to the aetiology of infantile diarrhoea. In his discussion of Czerny's
and Finkelstein's theories, which place bacteriological activity more or less
in the background, and which trace all the symptoms of infantile diarrhoea
to the chemical action of the food and its decomposition products, Bloch
remarks that these theories have involved their sponsors in a tangle of con-

ALIMENTARY DISEASES 13

tiadictions from which many authorities are straying; back to the simpler
theory of infection. Bloch qualifies his adherence to this teaching with the
reservation that no irrefutable evidence has yet been produced, proving that
infantile diarrhoea is due to infection.

On the assumption that this diarrhoea is due to infection, Bloch raises
the further question : Is it possible clinically to distinguish between various
cases of infantile diarrhoea according to their bacteriological aetiology in
the same way that the diarrhoea of typhoid, paratyphoid, dysentery and
paradysentery can be clinically distinguished ? Bloch's material includes all
the cases of. acute gastro-intestinal disease in infancy observed at the
Rigshospital in the period 1911-18 inclusive. The classification adopted was
clinical. (1) Acute dyspepsia, with 85 cases and no deaths. {'J) Acute
gastro-enteritis, 310 cases with a mortality of 24 per cent. (3) Acute gastro-
enteritis, complicated by chronic dyspepsia or infantile atrophy, 77 cases,
with a mortality of 30 per cent. (4) Symptomatic diarrhoea, i.e. cases
(figures not given) in which the diarrhoea was merely an incident of
a disease outside the digestive system.

In 461 of all these cases bacteriological examinations of the faeces were
made. In 21 or about 10 per cent, of all the cases of acute gastro-enteritis
examined bacteriologically, paradysenterj^ bacteria were found ; these cases
were scattered over several years and did not represent a single epidemic.
In onp case tj'phoid bacilli, and in five cases paratyphoid bacilli were found ;
but these, too, were isolated cases, not the result of a single outbreak. The
clinical manifestations of 21 cases of paradj^sentery varied greatly; some
were severe and some were exceedingly mild. In 14 out of 18 cases of
acute paradysenteric gastro-enteritis, blood w^as demonstrable in the motions,
but there were many other cases of haemorrhagic motions in which para-
dj^sentery could be excluded. The clinical course of the six typhoid or
paratyphoid cases was more uniform. In every case the onset of the disease
was sudden, and the diarrhoea and vomiting were accompanied by slight
fever. Apart from the bacteriological evidence in these cases, there w^as no
sign of typhoid fever, such as a roseola or enlargement of the spleen. The
clinical picture was that of mild, non-specific gastro-enteritis. The B. proteus
was found in 52 out of 128 cases of acute gastro-enteritis and in 95 out of
244 cases of acute dyspepsia and symptomatic diarrhoea. Bloch concludes
that the clinical picture, epidemicity, and the pathological-anatomical
findings in infantile diarrhoea are the same whether pathogenic bacteria are
found in the faeces or not. Acute gastro-enteritis in infancy is due to
infection, but not to any specific infection. In most cases coliform bacilli,
not pathogenic to adults or children over a certain age, are probably the
cause of this disease. In a minority of cases the disease is due to micro-
organisms pathogenic to adults.

Pseudo-ascites in children suffering from prolonged enteritis seems to
have been first described by Tobler in 1914, and other reports of the syndrome
have appeared since. Segagni now reports four cases in which were present
(a) very chi'onic diarrhoea, (6) enlargement and flattening of the abdomen,
(c) some degree of fluctuation and shifting dullness, and {d) very large
amounts of fluid in the bowel, but no excess of peritoneal fluid. The children
were all wasted and cachectic and the general appearance closely simulated
tuberculous peritonitis, for which several recorded cases have been operated
upon. Cure appears to be long and tedious and is not specifically dealt with
by Segagni.

14 REVIEWS

Barsony records two cases in Avhicli an extreme elongation and dilata-
tion of the colon gave rise to difficulty in swallowing, owing to pressure on
the subphrenic portion of the oesophagus. Tn the first case, which occurred
in a man aged 54, the condition of the colon was found to be secondary to
carcinoma of the rectum, which had hitherto not caused any symptoms.
After colostomy in the lower part of the descending colon the dysphagia
disappeared. In the second case, which occurred in a man aged 40, the
dilatation of the colon was apparently due to intestinal paresis following
enteritis, and was cured by a course at Carlsbad.

Treatment. The following modification of Sippey's method of treat-
ment of gastric or duodenal ulcer has been adopted by Hurst : 5 oz. of milk
(or preferably milk and cream in equal quantities) are given every hour
from 8 a.m. to 8 p.m. inclusive. To each feed gr. x of sodium citrate
dissolved in 2 drachms of emulsio magnesiae are added. Immediately before
alternate feeds, beginning at 7.30 a.m., ^ oz. of olive oil is taken. This inhibits
the secretion of gastric juice and also supplies a digestible and absolutely
unirritating food of very high nutritive character in a concentrated form.
Immediatelv before the remaining: feeds Cl)v tinct. belladonnae. which has
a similar inhibiting effect, are given, as oil before each feed sometimes gives
rise to nausea. Half an hour after each feed, and at 9, 9.30, and 10 p.m.,
a powder containing gr. x calcium carbonate and gr. xxx bismuth carbonate
is taken in a little water. At 6 a.m. \ oz. of bismuth carbonate, shaken up
but not suspended in 5-10 oz. of water, is swallowed and the patient then
lies on his right side or in such a position that the bismaith comes in contact
with the ulcer. This forms a protective covering to the ulcer and at the
same time neutralizes any acid present and calls forth a secretion of pro-
tective mucous. The stomach contents are thus kept neutral or alkaline
from 6 a.m. to 10 p.m. At 11 p.m. the stomach is completely emptied by
Senoran's evacuator ; if not more than 2 oz. are present on two consecutive
nights, this can be discontinued. If half a pint or more is removed at
11 p.m., the stomach should be evacuated again at 1 a.m. At 11 p.m. atropin
sulphate gr. -^^ is injected subcutaneously to inhibit the further secretion
of gastric juice. At the same time the alkaline pow^der should be repeated
every two hours through the night. This treatment should be continued
until for three weeks the patient has had no spontaneous pain, no trace of
tenderness has been present, no occult blood has been found in the stools,
not more than 2 oz. of fluid have been removed on any one evening, and
the X-rays showed no evidence of active ulceration. The diet can now be
rapidly increased until at the end of a week everything is taken with the
exception of chemically irritating substances, such as alcohol, vinegar,
mustard, pepper, pickles, &c.

Various physicians, such as Hurst in England, Albu in Germany, and
Bastedo in America, deprecate surgical interference in the treatment of
gastric or duodenal ulcer until a thorough medical treatment has been tried,
on the grounds of the risks of the operation, the tendency to recurrences
and unpleasant after-effects, such as hernia, rectus diastasis, gastro-intestinal
fistula, and peritoneal adhesions. Albu remarks that the majority of patients
in whom the operation has been unsuccessful do not return to the surgeon
but consult a physician, especially if a long time has elapsed since the
operation without improvement taking place. Bastedo maintains that
a case should only be regarded as surgical when it continues to show (1)
persistent recurrent haemorrhage even small in amount ; (2) pain ; (3)

ALIMENTARY DISEASES 15

nausea ; (4) pylorospasm of such persistence as to simulate pyloric stenosis ;

(5) inability to ingest comfortably ordinary wholesome foods or to take
enough food to maintain nutrition while leading a normally occupied life ;

(6) recurrence after an apparent cure. Other indications for operation men-
tioned by Hurst and Albu are perforation, hour-glass contraction, chronic
peritoneal adhesions, and the possibility of a growth being present.

Crohn and Reiss studied the eti'ects of restricted or so-called ulcer diets
on gastric secretion and mortality, and found that only a small percentage
reacted to medical treatment by showing a reduction of acid produced
during digestion. Clinical improvement, however, took place independently
of whether the hyperacidity was relieved or not. A similar conclusion was
arrived at with regard to hypersecretion, as improvement occurred as often
in cases with persistent hypersecretion as in those relieved of their excessive
flow of gastric juice, and was apparently not dependent upon it. As regards
the relationship between improved gastric motility and clinical relief, in
11 out of 13 cases of delayed motility treatment alleviated this symptom
and reduced the emptying time to normal. All these 11 cases w^ere also
■ freed from subjective complaints. No explanation could be given of the
relief of symptoms in cases not complicated by delayed motility in -which
the h3'peracidity and hypersecretion were not affected by treatment.

Eight benign cases of impermeable cardiospasm, by which is meant
failure of food to enter the stomach in the normal way, absence of organic
stricture, and impossibility of reaching the stomach by the usual gastric
tube or bougie, vrere treated b}^ Einhorn (2) with retrograde stretching of
the cardia soon after a previous course of duodenal alimentation. The
stretching is done first by the pjdoric dilator, every other day or twice
a week, the dilator being introduced at bed-time supplemented by a dose of
atropin and the stretching done the following morning. After a few
stretchings the dilator enters the stomach in a much shorter time.

Einhorn (3), who had previously recorded a case of duodenal perforation
successfully treated b}^ duodenal (jejunal) alimentation, reports another
successful case in a man aged 50. After three wrecks of jejunal alimentation
the tube was pulled up to some extent, so that the capsule end was situated
in the duodenum proper. It w-as found that duodenal alimentation suited
the patient much better, as he did not lose weight as he did on jejunal
feedinsf.

According to Bensaude and Vicente, rectal injections of a solution of
extract of bile causes an increase of peristalsis in the terminal portion of the
large intestine, resulting in the evacuation of the contents of the rectum
and sigmoid. This action is purely excitomotor and is not accompanied by
any excess of intestinal secretion. The use of bile enemata is therefore
indicated in temporary or habitual constipation when single enemata or
laxatives are ineffective. Powdered bile in doses of 4-5 grm. in i litre of
water does not produce any rectal pain or irritation, even wdien employed
for several weeks, and its habitual use does not interfere with its efficacy.

AI.BU, A. Zur Diagnose und Therapie des Ulcus duodeni. Ztschr. f. (irztl.
Fortbild., 1920, 17, 633-40.

ANTOnnE:, E. Les recto-oolites graves (I'ecto-colites hemorragiques et recto-
oolites purulentes). llieses cle Paris, 1919-20, 113.

BABSomr, T. Schluckbeschwerden bei Dickdarniprozessen. Wien. Win.
Wchnschr., 1920, 33, 729-30.

16 REVIEWS

Basch, S. Primary sarcoma of the stomach. N. YorJc ill. J., 1920, 112,
9-13.

Bastedo, W. a. Determination of the need of surgery in peptic ulcer, with
remarks on gastro-enterostomy. Am. J. 31. Sc, 1920, 160, 491-503.

Bensavde, K.., et Vicente, M. Les lavements de bile dans le traitement de
la constipation. Bull, et mem. Soc. med. d. hop. de Far., 1919, 3e ser , 43, 932-9.

BI.OCH, C. E. JEtiologien til de akute Fordoielseslidelser hos det spade Barn
og disse Lidelsers Inddeling og Behandling. UgesTc. f. Lager., 1920, 82, 745-64.

Boas, I. Die Behandlung des runden Magengeschwurs. Ztschr. f. arztl. Fort-
Uld., 1920, 17, 333-9.

Bruniitg, H. Ueber Mageninhaltsuntersuchungen bei Kindern. Beutsche med.
Wchnsclir., 1920, 46, 883-4.

Beunn, p., Hitzenbergee, K., u. Saxl, P. Ueber die Periodizitat der
Erscheinungen beim Magen- und Zwolffingerdarmgeschwiir. Wicn. Jdm.
Wchnschr., 1920, 33, 228-31.

Caritot, p. Les syndromes cliniques et radiologiques de la linite gastrique.
Paris med., 1919, ii, 481-6.

Cristoi. et Porte. Les kystes gazeux de I'abdomen. Presse med., 1919, 27,
726-7.

Crohn, B. B., and B.eiss, J. Effects of restricted (so-called ulcer) diets upon
gastric secretion and motility. Atn. J. M. Sc, 1920, 159, 70-93.

Du Bray, E. S. Gastric polyposis (papillomatosis). Report of a case with
operation and presumable cure. Arch. Int. Med., 1920, 26, 221-31.

Dunham, J. H. Errors in the diagnosis and treatment of duodenal ulcer.
Am. J. M. Sc., 1920, 160, 647-51.

DuPUY. Epreuve du repas fictif en pathologie gastrique. Paris med., 1920, ..

286-91.

EiNHOEN, M.{1). Further experience with the string test. J. Am. M. Ass.,

1919, 73, 1509-10.

EiNHORN, M. (2). On retrograde stretching in treatment of impermeable cardio-
spasm. Med. Bee., 1920, 97, 983-6.

EiNHORN, M. (3). Duodenal perforation (fistula) treated by duodenal (jejunal)
alimentation. Another case. /. Am. M. Ass., 1920, 74, 790-1.

Farneli., p. J., and Harrington, A. H. Acute infectious enteritis with a
polyneuritic syndrome. Am. J. M. Sc, 1920, 160, 52-61.

PiNSTERER, H. Ulcus duodeni mit Pfortaderkompression und Ascites.
Wien. med. Wchnschr., 1920, 70, 273-7.

Priedenwald, J., and Grove, G. H. The blood-sugar tolerance test as an aid
in the diagnosis of gastro-intestinal cancer. Am. J. M. Sc, 1920, 160, 313-23.

Friedman, J. C. Chronic non-specific entero-colitis, 3Ied. Clin. N. America,

1920, 3, 1699-1707.

Pritzsche, R. Ueber todliche primilre parenchymatose Magenblutungen.

Berl. Uin. Wchnschr., 1919, 56, 747-51.

De Gery, C. p. Les kystes gazeux de Tabdomen. Gas. d. hop., 1919, 92,

1229-33.

ALIMENTARY DISEASES 17

Hagoabd, W. D. Sarcoma of the stomach, with report of a case and an
analysis of 107 cases operated on. Surg , Gynec, ^- Ohst., 1920, 31, 505-11.

Hendricks, H. V. Chylous ascites due to carcinoma of the stomach. J. Am.
M. Ass., 1920, 74, 869-70.

HuBST, A. p. New views on the pathology, diagnosis, and treatment of gastric
and duodenal ulcer. Brit. M. J., 1920, i, 559-63.

Jabdet. Hvdroparotides intermittenles causees par les dentiers. J. cle med.
cf chit: prat, 1920, 91, 307-12.

KoETTLiTZ, H. Un cas de sarcome de Testomac. Arch. mccl. helg., 1919, 72,
136-43.

Lemon, W. S. Angioma of the stomach. JSIcd. Bcc, 1920, 97, 220-2.

Lenobmant, C. Les kystes gazeux de Tabdomen. Presse mod., 1920, 28,
104-7.

LiCHTENSTEiN, A. Nagra ord om pylorospasm och pylorus behandling.
Hijgeia, 1919, 81, 627-32.

Neubeb, E. Die Operation eines gestielten Magenmyoms. Wien. Tdin.
Wchnschr., 1920, 33, 838-40.

NicoiiAYSEN, K. Irritation of the vagus and haemorrhagic erosions of the
stomach. Arch. Int. Med., 1920, 25, 295-305.

NzTCH, C. A. R., and Shattock, S. G. Diffuse emphysema of the intestinal
wall (two cases), with remarks upon pneumatosis. Proc. Bog. Soc. Med., 1919,
12, Sect. Path , 46-86.

Novak, E. Polypoid adenoma of the stomach. Removal by gastrotomy.
J. Am. 31. Ass., 1920, 74, 871-2.

B.AMOND, F. Le spasme du pylore (pylorospasme). Presse med., 1920, 28,
273-5.

Ramond, F., et Clement, R. Spasme pylorique continu et dilatation gas-
trique. Bull, et mem. Soc. med. d. hop. de Par., 1920, 3^ ser., 44, 616-19.

REHFUS3, M. E., and Hawk, P. A study of hyperacidity. Am. J. M. Sc,
1920, 160, 428-33.

RosZiEB, O. A. i'ber die Beziehungen der chronischen Bleivergiftung zum
Magengeschwiir (Beitrag zur Frage der Ulcuspathogenese). Med, Klin., 1920,
16, 1057-60.

Seoagni, S. La pseudoascite nei bambini. PolicUn., 1920, 27. Sez. Prat.,
431-4.

SiNGEB, G. Hypertonlsche Magen-Darmblutung (1. Polycythaemia hyper-
tonica. 2. Aortitis syphilitica). Miinchen. med. Wchnschr., 1919, 66, 1165-7.

V. S0HI.EBN. Uber Darmblutungen. Med. Klin., 1920, 16, 753-5.

Stoyanovitch, M. D. Kystes gazeux de Tintestin. Theses de Paris, 1918-19,
230.

Stbauss, H. Uber Ulcus parapyloricum. Die Therap. d. Gegemv., 1920,
N. F., 22, 379-85.

Stbauss, R. Zur Diagnose des Magenkarzinoms (unter besonderer Beriick-
sichtigung der Sekretionsbefunde). Berl. Idin. Wchnschr., 1920, 57, 251-4.
IV. C

18 REVIEWS

TuRRETTiNi, G., et Gerber, I. Cancer precoce d'estomac et lymphangite
cancereuse pulmonaire generalisee. Jiev. med. de la Suisse Rom., 1920, 40,
177-84.

Vaurs, R. Perforation de I'estoraac cancereux par sphacele de la paroi.
Theses de Paris, 1919-20, 71.

ViCEWTE, M. Les lavements de bile dans la constipation. Tlieses de Paris,
1919-20, 18.

WeiI:, M. p. La pneumatose cystique de I'intestin : etude clinique. Ann. de
med., 1920, 8, 11-29.

J. D. R.

C. L.

G. W.

DIPHTHERIA

Epidemiology. Dubourg and Guenavd give statistics showing the
mortality from diphtheria at the Children's Hospital at Bordeaux during
the thirty years 1888-1917. In 1888 and 1889 the eases were nursed in
a general ward with an average mortality of 49 per cent, and a maximum
mortality of 54 per cent, in 1888. From 1890 to 1893 the cases were
admitted to a special block, and there was a decided fall in the mortality,
since it was 35 per cent, during this period. In 1894, with the creation of
separate cubicles for each patient, it fell to 19'4 per cent., the lowest figure
reached before the introduction of antitoxin. Since 1895, when antitoxin
was first employed, the average mortality has been 7*28 per cent, with
a maximum of 15-5 per cent, in 1899-1900, and a minimum of 1-53 per cent,
in 1907 (3 deaths among 195 cases). The number of operations for laryngeal
diphtheria has also fallen considerably; in 1894 56 per cent, of the admis-
sions required tracheotomy. After the introduction of serum and before
intubation became current the annual average of tracheotomies fell to 9-87
per cent, of the admissions. After the introduction of intubation the
number of operations including both intubation and tracheotomy was 15-34
per cent, of the admissions.

Huntemiiller records an epidemic of diphtheria in the 19th Bavarian
Infantry Regiment fighting in Lorraine, and considers the causes of the out-
break to be as follows: (1) the general diminution of resistance due to the
hard work involved in building the trenches, insanitary quarters, and bad
weather ; (2) the local irritation of the chalk dust produced while working.
After the trenches had been completed there was a steep fall in the morbidity.
That this was the effect of increased resistance of the troops and not the
result of a diminution of the infectivity or virulence of the diphtheria
bacilli was shown by the large number of carriers who were subsequently
discovered and by the occurrence of a fatal case.

Aetiology. In view of Savage's recent contention that there is no
foundation for the popular belief that cats may suffer from diphtheria
(vide Medical Science, 1920, 2, 358-9), the case reported by Simmons
is of considerable interest. The patient was an elderly lady who de-
veloped a fatal attack of faucial diphtheria after fondling a cat which

DIPHTHERIA 19

had been ill one week before her illness began. The cat was said to
have liad a croupy cough, to have been unable to swallow food, and to
have become very thin. Throat cultures from the cat and from the
patient showed morphologically similar organisms resembling diphtheria
bacilli, and their virulence for guinea-pigs was the same. The cat was
killed, and a post-mortem examination revealed a small ulcer covered with
a yellowish membrane on the upper surface of the left nasal fossa, cultures
from which yielded diphtheria bacilli. No lesions in the internal organs
were found. A second cat which had played with the first and yielded
a throat culture showing morphologically typical diphtheria bacilli, died
after eight days' confinement in a cage and pod onortem showed small
membranous patches on the vocal cords, from which virulent diphtheria
bacilli were grown. The history of contact, dates of infection, and bacterio-
lofifical findinofs suofoested that the first cat was the source of infection of
the patient as well as of the second cat, though this could not be absolutely
proved. It was certain, however, that both cats were carriers of virulent
diphtheria bacilli and were therefore a danger to human beings.

Cartesegna and Casassa of Turin, examined catheter specimens of the
urine in 100 cases of diphtheria and found diphtheria bacilli present in 85 per
cent. They are convinced that,by slight improvementof techniqueand frequent
examination of a larger quantity of urine, positive results could be obtained
in all cases. The presence of the bacilli was independent of the severitj^ of
the case. It was impossible, for obvious reasons, to continue investigations
on the same individual until the examination became negative, but it was
an almost invariable rule for the urine to be still positive one and a half
months after the onset of the attack, when the faucial cultures were nega-
tive. The diphtheria bacillus was never found in pure culture in the urine,
but always in association with other micro-organisms, such as the strepto-
coccus, B. coli, pneumococcus, the Brisou coccus, and Friedliinder's bacillus.
The practical importance of these observations is that excretion of diphtheria
bacilli in the urine should be taken into consideration in dealing with
carriers.

Symptomatology. A case of isolated diphtheria of the mouth in a
breast-fed infant, aged 14 days, is reported by Janssen from the Gottingen
University Children's Clinique. The region affected was the alveolar margin
of the upper jaw on either side of the mid-line. Diphtheria bacilli were found
in cultures of the lesions, whereas nasal and faucial cultures were negative.
2,000 units of antitoxin were injected and the condition rapidly cleared up.
Though secondary diphtheria of the mouth, which usually appears in tne
form of ulcers, is well known, Janssen has been unable to find any record
of a case of primary diphtheria of the mouth.

According to Lambert, primary dipMheria of the middle ear is observed
in both sexes, and in adult life as well as in childhood, though like all forms
of diphtheria it is commonest in early life. Infection takes place from the
pharynx or nasal fossae by the Eustachian tube. The condition is charac-
terized by the association of the following three symptoms : intense and
persistent pain, pronounced bulging of the tympanic membrane, and a
sero-haemorrhagic discharge, sometimes containing whitish-grey pieces of
membrane. If recognized in time and treated by antitoxin the condition
rapidly clears up, especially if it is not complicated by a secondary infection,
but if it is not recognized or treated until late, it tends to become chronic
and to be complicated by mastoiditis or facial paralysis, which may even occur

c 2

REVIEWS

during the first few days, so that primary diphtheria of the ear cannot
be regarded as a mild form of ear disease.

Although dqjJitheria of the vulva is relatively frequent in small children,
usually secondary to faucial diphtheria, this localization is extremely rare
in adults. Kromayer of Berlin, reports a case in a woman aged 22, who, in
May 1919, had contracted syphilis, for which she was treated with salvarsan
and mercury. When she was seen in the following August she presented
a profuse yelloAV vulvar discharge and several ulcers round the clitoris and
urethral orifice which were regarded as soft chancres. The ordinary treat-
ment for this condition had no effect, and the ulceration became more
extensive. When the patient was seen by Kromayer, on November 5, the
floor of the ulcer was covered by a thick white adherent membrane, smears
from which showed diphtheria bacilli. 3,000 units of antitoxin were given,
and within three weeks the ulceration had completely healed. There does
not appear to be any similar case on record of vulvar diphtheria simulating
soft chancre.

Leendertz of the Konigsberg University Medical Clinique, records a case
of primary dqjhtheria of the vagina and sJdn of the intergluteal folds in
a child aged 5^ years, in whom nasal and faucial diphtheria were absent.
A brother and sister of the patient had recently suffered from diphtheria.
The truth of Trousseau's doctrine that diphtheritic paralysis begins in the
region first attacked by diphtheria was exemplified in this case. The first
paralysis occurred in the bladder, as was shown by incontinence of urine, on
the ninth day after disappearance of the membrane, and was followed by
paralysis of the rectum (incontinence of faeces) eighteen days later, or on the
forty-eighth day of disease. On the forty-ninth day paralysis of the palate,
third and sixth cranial nerves, and ataxia of the legs were observed. All
the palsies gradually disappeared. The origin of the bladder palsy in this
case can be explained as in the case of palatal palsy after faucial diphtheria
by a direct ascent of the toxins. The subsequent palsies are regarded by
Leendertz as the result of toxins circulating in the blood, when, according
to recent investigations, they may persist for a long time, especially in the
lungs.

Peiper, alluding to the frequency of vulvar and cutaneous diphtheria
durino- the war. attributes this occurrence to defective cleanliness of the skin,
which was chiefly due to the absence of soap.

After noting that diphtheria of the umbilicus was first described in
1860 by a Norwegian, Moller, whose patient, a new-born child, died after
an illness of 12 days, Schonf elder gives an account of an important epidemic
observed in Christiania in 1919. The first case was that of an infant, born on
April 13 at a maternity hospital, and admitted to Ullevaal Fever Hospital
on May 10. The diphtheritic nature of the umbilical inflammation was not
recognized till after death, on May 28, when diphtheria bacilli were found.
The necropsy showed no sign of peritonitis apart from a limited patch
of redness and hyperaemia on a part of the large intestine situated immedi-
ately beneath the umbilicus. Between May 19 and November 15, 130 patients
were admitted from the maternity hospital to the fever hospital, of whom 33
were infants with umbilical diphtheria. These cases were grouped in four
classes according to the severity of the disease, 10 being in the first class, 19
in the second, and 2 in each of the last two classes. In the first class the
condition of the umbilicus, from the clinical standpoint, was practically
normal. The diagnosis depended on the routine bacteriological examina-

DIPHTHERIA 21

tions of tlic umlulicus wliich, <lurin<( the epidemic, were undertaken at the
maternity hospital. These cases may, therefore, be i-e^arded as ' carriers ' ;
as they were at once treated with antitoxin, it is impossible to say whether
they would subsequently have developed into clinically demonstra])le diph-
theria or not. In the second class, indolent ulcers, up to the size of a small
coin, were coated with a *^reenish-yellow dischar<^e, but not with a typical
pseudo-membrane. In the remaining two classes there was extensive
infiltration and an erysipelas-like redness about the umbilicus which formed
an ulcerating prominence as large as a Spanish nut. The depth of the
ulceration in one of the cases in the fourth class was so great that the
patient's escape from peritonitis was remarkable.

Discussing the frequency of umbilical diphtheria, Schonf elder points
out that, as the disease is seldom clinically distinguishable from non-specific
infections, it must often be overlooked. Every infection of the umbilicus,
especially during an epidemic of diphtheria, should, therefore, be suspect,
particularly if the infant snufiles. It is curious that while se\ere diphtheria
of the throat often kills the patient in a few days or a week, diphtheria of
the umbilicus lasts several weeks, and for a considerable time does not
disturb the general health. Even in the one case which terminated
fatally the duration o.f the disease was 30 days. The disease is seldom
febrile, and only in 3 out of the 33 cases was the temperature raised. The
absence of fever was particularly remarkable in the worst cases, and this
point is of value in the differential diagnosis, for in non-diphtheritic infec-
tions the height of the temperature is directly proportional to the severity
of the local reaction. In 2 cases diphtheria bacilli were also found in the
nose, and in 3 in both nose and throat.

Reviewing his own experience and others, Schcinfelder concludes that,
in severe cases, the prognosis is bad without antitoxin. He gave 4,000 units
and, in the worst cases, 6,000 units. Remarking on the fact that no case
of umbilical diphtheria has been reported in Norway between 1861 and 1919,
Schonfelder finds it strange that in this year many cases should have occurred
both in Bergen and Christiania, He correlates these outbreaks with a sudden
rise in the frequency of diphtheria of the skin in 1919. Thus, in 1916, among
912 notifications of diphtheria, there was only 1 of skin infection. In 1917
there were 5 such cases among 926 notifications, and in 1919 there were 32
among about 1,700 notifications. It is also instructive that in 1860 the
occurrence of umbilical diphtheria coincided with many cases of wound
diphtheria. As to the source of infection at the maternity hospital, no
' carriers ' could be found on its permanent staff*, but some of the mothers
were found to be infected on admission.

Looft, who records two cases of diphtheria in the new-born, in one of
which the umbilicus was affected, maintains that diphtheria is not, as
commonly supposed, rare in the new-born. It should always be suspected
in the presence of snuffling, otitis, lesions of the skin, and, not least, inflam-
matory conditions of the umbilicus. In his first case, a new-born infant was
infected by another child in the same family, suffering from nasal diphtheria.
The infant's snuffling was regarded by the parents as a simple cold, and, as
it seemed well in other respects, medical aid was not sought. After about
three weeks numerous paralyses developed in rapid succession ; the muscles
of the neck and those supplied by the lower branches of the facial nerve
were involved, as well as all four limbs. There was absence of tendon re-
flexes with anaesthesia and, in two places, hyperaesthesia. This polyneuritis

22 REVIEWS

miglit well have led to the diagnosis of Heine-Medin's disease, had not
diphtheria bacilli been found in the nose. No antitoxin was given, and only
palliative measures were adopted. Death occurred after eight days' illness,
when the child was about five weeks old. The chief interest attaching to
the second case, one of umbilical infection, was the promptness with which
the patient recovered after the injection of 650 units of antitoxin supple-
mented by compi-esses of Burow's solution. It transpired that the mother
had recently suffered from ' a cold ', and diphtheria bacilli were found in her
throat. They were still there a month later.

After referring to five cases of umbilical diphtheria observed by Axel
Looft in 1919 at a maternity hospital in Bergen, C. Looft discusses the
clinical picture and remarks that its uniformity, as taken for granted by the
follow-my-leader writers of text-books, is purely hypothetical. Umbilical
diphtheria is in reality extraordinarily polymorphous, and apart from
bacteriological findings, there is nothing constant. The same applies to
wound diphtheria, which shows every degree and kind of inflammation from
phlegmon and gangrene to a reaction which is so slight that only the
bacteriological examination clinches the diagnosis.

Goppert states that the great majority of cases of diphtheritic infection
of the umbilicus occur at the end of the first week of life or in the course of
the second week. The disease may, however, develop much later. In such
cases the child may be suffering from nasal diphtheria or be a diphtheria
carrier, so that the infection may have arisen in a lying-in hospital. A larger
proportion of the cases, according to Goppert, show hardly any symptoms.
A slight dampness of the umbilicus may prompt an examination which
shows a thin deposit in the folds of the umbilicus or on the granulating
umbilical wound. In other cases, especially those in which the infection
occurs in the first few days of life, the disease runs a much more maKgnant
course even from the first. Ulceration, with infiltration of the .'surrounding
areas, occurs, and even gangrene of the navel may develop. Most cases of
diphtheria of the umbilicus, like diphtheria of the new-born, generally
originate in lying-in hospitals, though the infection may sometimes occur in
a private house.

Henkel, who records four illustrative cases, agrees with von Reuss, who,
in his text-book on diseases of the new-born, states that diphtheria of the
umbilicus does not present a characteristic or specific appearance, and that
the diag-nosis must be made by bacteriological examination, which should be
carried out as soon as possible. Diphtheria of the umbilicus may be associated
with diphtheritic processes elsewhere, e. g. in the nose, conjunctiva, skin, &c.,
but this is not necessary, and it is usually the only localization of diphtheria,
as in the cases reported by Henkel. The general condition is not aflected
at first, and it is only when the disease has made considerable progress that
constitutional disturbance takes place. As a general rule, in Henkel's
experience, diphtheria of the umbilicus is not a severe infection, provided it
is recognized early before a mixed infection occurs.

Prausnitz records five cases of diphtheria of the umbilicus, four of which
occurred in new-born children and three of which were fatal. In the first
case death was due to generalized paralysis, in the second to staphylococcal
peritonitis, secondary to the umbilical infection, and in the third to debility
resulting from concurrent nasal and umbilical diphtheria.

Snell reports eight cases of diphtheria of the umbilicus from the
Gdttingen University Children's Clinique. Three of these had severe,

DIPHTHERIA 33

two motlerate, and tliree mild attacks. Death, which was sudden, occurred
in three cases, being due in one case to erysipeUis, and in the other two to
broncho-pneumonia. Paralysis of any kind was not observed. Concurrent
nasal diphtheria was present in five cases. In two cases pyogenic organisms
were found, in one in the blood, and in the other in a section of the uml)ilicus.
In three cases the disease occurreil in the first few days of life, and in the
others in the second week or as late as the fourth week.

At the Greifswald Medical Society on June 20, 1917, Peiper showed
a case of diphtheria of the penis and lunbilicus in a new-born infant.
Diphtheria bacilli were also found in the nose and throat, without, however,
any clinical evidence of disease in these regions. The source of infection
was the mother, who was suft'erinof from intertrio-o in the secretion from
which diphtheria bacilli were present. Peiper also alluded to the frequency
of diphtheria carriers among the new-born, no less than 36 per cent, of the
children admitted to an infant's home beino- found to be carriers.

Wieting maintains that uviind diphtheria, on which so much has
recently been written (vide Medical Science, 1919-;20, 1, 151-4 ; 404-9), is
simply the old hospital gangrene which was by no means uncommon in the
military hospitals in the campaign of 1870-1, but under the influence of
the aseptic and antiseptic methods of peace time had become practically
unknown.

A case of diphtheria, with multiple and subintrant rela])ses, is reported
by Boidin. The patient was a soldier who had an attack of diphtheria which
was treated in the ordinary way. After the acute symptoms had subsided
he remained w^ell for six wrecks and then developed a condition of chronic
sore throat with periods of transient improvement. It was not until five
months had elapsed that the sore throat, which had been regarded as
herpetic angina, was recognized as diphtheria and treated as such. After
remaining well again for six weeks the patient had another relapse, eleven
months after the initial attack, and infected other soldiers.

E. Aaser has attempted to calculate the incidence of heart failure
in diphtheria by comparing the deaths with the actual number of cases
treated at UUevaal Fever Hospital at various periods. He classifies his cases
in four groups, according to the severity of the disease, and he excludes from
his analyses cases complicated by other diseases, as well as ' carriers '. In
the pre-serum period, 1890-4, there were 858 cases in the first group with
only 8 deaths. In the second group there were 245 cases with 48 deaths.
In the tliird group there were 89 cases with 55 deaths. In the fourth group
there were 30 cases wdth 27 deaths. Thus the mortality percentages for
the four groups were 1, 20, 70, and 90 respectively. Comparing these figures
with those for 1915-18, he shows that in the first two groups there w^'re no
deaths, in the third group the mortality was only 1 per cent., and in the
fourth group only 19 per cent. The total number of cases in this 4-year
period was 1,856. Thus, the mortality among the fourth group cases treated
with serum was practically the same as that for the second group cases
treated without serum. But though serum treatment has thus greatly
reduced the mortality, it has, in Aaser 's opinion, done little or nothing
to reduce the incidence of cardiac complications late in the disease. He
even thinks that these may be promoted by the serum on account of its high
carbolic acid content (0-5 per cent.). He gives no figures indicating the
frequency of non-fatal cardiac complications, but he suggests that if physicians
dared undertake functional heart tests on their patients on the day of

24 REVIEWS

discharge a very large proportion would react with signs of cardiac insuffi-
ciency. The treatment he recommends is absolute rest, with morphia to com-
bat restlessness and insomnia in children as well as adults. An ice-bag over the
heart, laxatives, and flushing the system with fluids are also recommended.

Marriott reports a case of post-diphtheritic iKLvalysis of the respiratory
muscles in a girl aged 10 years, whose life was saved by prolonged artificial
respiration. An apparatus designed by Gesell and Erlanger for administer-
ing artificial respiration to animals was used and was employed at intervals
for five days, at the end of which time the respiratory muscles had so far
regained their function that artificial respiration was necessary only at
relatively infrequent intervals. Complete recovery took place.

From a study of the literature and observation of six cases of diph-
theritic paralysis, in which examination of the cerebrospinal fluid was made,
De Lavergne comes to the following conclusions : (1) Diphtheritic paralysis,
whether confined to the soft palate or generalized, is accompanied, as a rule,
by a meningeal reaction. (2) I'his reaction consists in an excess of glucose
and albumin in the cerebrospinal fluid with a normal lymphocytosis. (3) This
reaction is probably present a little before the appearance of the paralysis.
The excess of glucose in the cerebrospinal fluid is the first sign, and persists
until clinical recovery.

Diphtheritic paralysis of central origin, of which Riemschneider reports
a case, is very uncommon. In 1913 Rolleston (1) collected 80 cases of diph-
theritic hemiplegia, including six of his own, in patients aged from 1^ to
17 years. Right hemiplegia occurred in 48 — in 21 of whom aphasia was
noted — left in 27, and in 5 no details were given. The occurrence of the
hemiplegia took place at the following dates : in the first week 1 case ; in
the second week 14 ; in the third 27 ; and in the fourth to the seventh 12.
In 14 cases in which no exact date is given it is said to have developed in
convalescence ; in 12 no date whatever is given. Recovery took place in 52,
death in 24, and in 4 no details were given. Necropsies were held in 18
cases. Embolism was found in 13, thrombosis in 3, haemorrhage in 1, and
sclerotic atrophy in 1. In all the cases where details are given the initial
attack was severe. Albuminuria and ordinary diphtheritic paralysis
developed in a large number. The prognosis in diphtheritic hemiplegia, as
in hemiplegia generally following acute infections, is unfavourable as regards
complete recovery. In the great majority of cases contractures and atrophy
have supervened in the paralysed limbs. Rolleston (2), however, has
recently reported two cases of diphtheria in which the hemiplegia, though
complete and accompanied by aphasia and characteristic changes in the
reflexes, disappeared within 24 hours. Though one case recovered and an
autopsy could not be obtained in the other, which proved fatal, it is probable
that uraemia was the cause of the paralysis in one case and minute emboli
in the other.

Diagnosis. Hesse of the Halle University Medical* Clinique, describes
an auscultatory sign for diagnosing laryngeal diphtheria which, in the
absence of concomitant faucial involvement, can only be recognized by
laryngoscopy or the presence of diphtheria bacilli in the sputum. Hesse's
sign consists in the normal broncliial breathing being replaced by extra-
ordinarily rough and sharpened breath sounds. The phenomenon, which is
present not only in laryngeal diphtheria accompanied by stridor or recession,
but also in the non-stenotic form of the disease, is best heard over the lateral
aspect of the thyroid cartilage or over the cricoid or upper rings of the
trachea.

DIPHTHERIA 2

:io

Prophylaxis. The determination of susceptibility to diphtheria by the
Schick test, and the immunization ot" those found to be susceptible by toxin-
antitoxin, have formed the subject of immerous recent papers. Bauer, who
is in charge of Schick testing and active immunization for tiie Philadelphia
Department of Health, has made observations on 3,000 children with the
following results : up to six months infants enjoyed immunity, from six
months to three years 72-5 per cent, were positive, from three to five years
46 per cent., from five to ten years 3:2'4 per cent., from ten to twenty years
28-2 per cent., and over twenty years 13-2 per cent. 1,100 persons who
were found to be susceptible to diphtheria by the Schick reaction were given
toxin-antitoxin. 200 of these were retested at the end of five months, and
all gave a negati\e test. A reaction due to the protein contained in the
mixture occurred in a few individuals and consisted in malaise, headache,
fever up to 101-3°, joint pains, and leucocytosis. The reaction usually
occurred after the tirst injection, and was milder after the second or third
dose, if it occurred at all.

Blau studied the Schick test and active immunization against diphtheria
with toxin-antitoxin at the Stuyvesant Clinic of the Department of Health,
and found that more than a third of the children under 14 were susceptible
to diphtheria, i. e. had no natural immunity against the disease. The greatest
susceptibility was between 1 and 6 years. After the age of 6 years the
degree of susceptibility gradual!}' diminished, as shown by the negative
Schick tests. Of a total of 227 negative Schick tests 136 were between 6
and 14 years. Blau considers that the immunity proiluced by three injec-
tions of toxin-antitoxin is probably permanent. The development of an
active immunity is determined by the Schick test at the end of three
months. If the test is negative, the person is immune. By re-injecting
those who give a positive test an immunity can be developed in all suscep-
tible persons. Blau, however, points out that, as the immunity afforded by
toxin-antitoxin does not develop until the lapse of from two to twelve
weeks, active immunization with toxin-antitoxin cannot be utilized to protect
persons within that period.

Owing to an outbreak of diphtheria in a state industrial school, Lilly
performed the Schick test on 257 persons aged from 15-21, and obtained
positive results in 148 and negative in 109, The susceptible ones were then
given three doses each of 1 c.c. toxin-antitoxin at intervals of seven days,
in only 33 per cent, was there any general reaction, and in a much smaller
number a slight local reaction. The general disturbance was much less after
the second dose, and almost nil after the final injection. Two months later
all the boys who had had the toxin-antitoxin were given a second Schick
test, and out of 98 only 18 showed a slight reaction after 72 hours, and
13 showed a very slight pigmentation at the end of a week. A third test
was performed three months after the immunization, when only six showed
a slight reaction. Two boys contracted diphtheria after two injections of
toxin-antitoxin, and one on the day following the last injection. These cases
were treated with ordinary antitoxin and recovered promptly. Lilly con-
cludes ( 1) that toxin-antitoxin gives absolute immunity to diphtheria when
more than one month has elapsed after its administration; (2) that it does
not cause such troublesome and alarming reactions as ordinary antitoxin
often does ; (3) that the immunity persists indefinitely. He points out, how-
ever, that toxin-antitoxin has no curative properties and does not immediately
protect against diphtheria, and that the Schick test is not rapid enough to

26 REVIEWS

be of immediate use in cases exposed to clinical diphtheria, and should be
employed only to separate immunes from non-immunes.

Armand-DeHlle and Marie investigated Schick's test in more than 200
children belonging to several orphanages and obtained positive results in 75
cases, or 37-5 per cent. Thej'^ found that in children of the same family the
reaction was almost always the same, and that it was negative in healthy
carriers.

Renault, while emphasizing the importance of Schick's reaction in the
epidemiology and prophylaxis of diphtheria, points out that it does not
render unnecessary the investigation and isolation of carriers, as these are
to be found both among those who are susceptible and those who are
refractory to infection by diphtheria.

Leete examined the Schick test in 500 cases of scarlet fever and found
positive results in 57*2 per cent. Positive reactions diminished with
increasing age, but were more frequent among scarlet fever patients than
normal adults of the same age. In a series of normal adults only 17, or
28 per cent., were positive as compared with 37-5 per cent, in a corresponding
group of scarlet fever patients. Of 32 diphtheria cases Leete found that 18
were negative and 14 positive to the Schick test, this fact showing that
immunity may depend on other factors than the presence of antitoxin.

From a study of Schick's test in cases of diphtheria, non-diphtheritic
angina, and diphtheria carriers among soldiers, Rieux and Zoller recom-
mend that the test should be performed on every new recruit and the result
noted in the soldier's book, only those with a positive reaction requiring
immunization.

De Lavergne and Zoeller report four cases of diphtheritic paralysis
with a negative Schick's reaction. This shows that even in a state of
active immunity gradually conferred by an attack of diphtheria the anti-
toxin, which is in a sort of nascent condition, does not succeed in neutralizing
the toxin fixed in the nerves.

Park states that in 95 per cent, of the cases injected toxin-antitoxin
gives an immunity, which develops between the fourth and twelfth week
and persists for at least three and a quarter years. He mentions that the
injections are absolutely harmless, 1,950 babies from three to five days old
having been injected without any ill etfects. The older the patient the
more severe the reaction, this being due to the presence of peptones and
other foreign products in the broth and not to the toxin- antitoxin itself.
The method of administering the toxin-antitoxin recommended by Park is
injection of 1 c.c. subcutaneously or intramuscularly with the finest needle.

As the result of a recent inquiry Bieber has found that inoculation
with toxin-antitoxin in the Magdeburg- district in 1913 conferred a definite
if not absolute immunity against diphtheria, the results being sufficiently
encouraging to make a more extensive use of the method in districts
exposed to diphtheria advisable.

The gist of A. H. Meyer's paper is in the question : Does diphtheria
break out so frequently in children's wards as to warrant special prophy-
lactic measures ? Since the writer's clinic was started, in July 1905, about
2,400 patients have been treated, the average number of occupied beds out
of 24 being 20. During the following 14 years, 28 cases of diphtheria
developed in the hospital. In the first 10| years there were only 7 cases
among 1,700 patients, whereas in the last 3 years there were 21 cases among
onl}^ 700 patients. Since March 1910 every patient was examined on

DIPHTHERIA 27

admission for diphtheria bacilli, and in this way 21 'carriers' were detected
and prevented from spreading infection. Up till March 1916 the writer
flattered himself that his comparative immunity fro]n outbreaks of
diphtheria was due to these precautions. His more recent experience
convinced him that even when the nose as well as the throat is examined
for diphtheria bacilli, and the examination is repeated a week later,
' carriers ' are still able to elude detection in a certain proportion of cases.
But though his measures proved imperfect, the fact that he did intercept
21 'carriers' has convinced him that this .system of examining all
admissions for ' carriers ' is useful. As for the procedure to adopt
when diphtheria has already broken out, he used to give prophylactic
injections of serum till nine years ago when, for fear of anaphylactic shock,
he abandoned this treatment. Of the wisdom of this course he is still
in doubt.

Treatment. In a review of 25 years' antitoxin treatment Martin
states that in the pre-antitoxin era the highest mortality from diphtheria
per 100,000 inhaljitants was 200 deaths (Berlin 1883) and 100 (Paris 1882) ;
since the introduction of antitoxin the highest mortality for Paris was 27*7
deaths per 100,000 during the epidemic of 1901-2. The minimum figures
were 6-4 per 100,000 for Paris in 1906, 3 per 100,000 for Havre in 1908,
and 2-6 per 100,000 for Utrecht in 1908. As a general rule, before serum
therapy, the average mortality per 100,000 below 100 was above 50. Since
serum therapy had been introduced the average number of deaths had
been almost always less than 20, and often less than 10 per 100,000
inhabitants.

Hospital statistics. During the years 1890-93 incluf-ive, of 3,971 cases
admitted to the diphtheria block of the Hupital des Enfants Malades,
2,029 died — a mortality of 51-75 per cent. In cases treated by serum from
February to July 1894 the mortality was 24-5 per cent. The lowest death-
rate in this hospital was reached in 1904, when Marfan andLe Play reported
a mortality of 7-4 per cent. Before serum treatment the average mortality
of faucial diphtheria was 34 per cent, ; since the introduction of serum it
has been about 10 per cent. The mortality from operations for laryngeal
diphtheria, which was previously 73 per cent., is now about 20 per cent.,
and the number of operations required has considerably diminished. In
the years 1887-94, 36 per cent, of the admissions required operation ; since
then the number of operations has fallen to less than 15 per cent.

At the Pasteur Hospital, 1,624 cases have been admitted from 1900-19,
with 133 deaths, or a mortality of 8-18 per cent. As a general rule the
mortality at this hospital has ranged between 10 and 15 per cent., or more
than two-thirds less than in the pre-antitoxin era.

Diphtheria in the army. Before serum treatment diphtheria was
rare in the French army. According to Bayeux, from 1888-94 there were
3,551 patients and 393 deaths, or an average mortality of 11-07 per cent.
In 1895 and 1896 the mortality fell to 5-65 per cent., and in 1897-1914
was only 3-3 per cent. During the five years of the war, in the Army of
the Interior, i. e. in the hospitals situated outside the zone of the armies,
there were 15,271 patients and 378 deaths, or a mortality of 2*4 per cent.
In the zone of the armies there were 11,433 cases and 229 deaths, or
a mortality of 2 per cent.

Diphtheria 'mortality in Parish Before the introduction of serum
1,432 persons died annually in Paris from diphtheria, whereas during the

28 .REVIEWS

last few years this fioure has dropped to 130. Before serum treatment the
maximum number of deaths a week was 45 and the minimum 14 ; since
1898 the maximum number of deaths was 20 in 1898, and the minimum
1 in 1918.

The intramuscular route for injection of antitoxin, widely employed in
Germany and the United States and recommended in this country by Ker
and Rolleston and Macleod, has recently been adopted by French physicians
such as Netter, Weill-Halle, and Armand-Delille. Weill-Hall^ agrees with
Rolleston and Macleod, who had claimed the following advantages for the
intramuscular method : (1) It is quite as simple as the subcutaneous method,
ensures more rapid absorption, and is less liable to give rise to abscesses at
the injection site. (2) It is superior to the intravenous method not only in
the greater simplicity of its technicjue, but also in the less rapid excretion
of antitoxin after injection. (3) The more rapid absorption of antitoxin by
the intramuscular route is shown by lesser incidence of paralysis, especially
of a severe kind.

Owing to the greater rapidity of elimination of antitoxin when
administered by the intramuscular route, Armand-Delille recommends that
intramuscular injection should be supplemented the following day by sub-'
cutaneous injection of antitoxin in sufficiently large doses.

Alluding to the objection made by opponents of his method that the
favourable results were due to his havino: used serum from horses which
had formerly supplied antitoxin (vide Medical Science, 1919, 1, 156), Bingel
states that he had had the serum examined for its antitoxin content, with
the result that the serum supplied him by one firm was entirely free from
antitoxin, and that supplied by another contained only a negligible
quantity (3 units in 1 c.c). He adds that he has made no experiments as
to the prophylactic action of diphtheria antitoxin, the value of which he
has no reason to doubt. He also declares that he has never disputed
the therapeutical value of antitoxin, but has merely seen no difference
between its therapeutical results and those of normal serum.

Herzfeld, from his experience at the Leipzig University Medical Clinic,
found that the use of ordinary horse serum had the following disadvantages :
(1) The deposit in the throat persisted longer. (2) Paralyses were relatively
frequent even after mild faucial diphtheria. (3) Cases of cardiac death,
especially in adults, were more frequent. (4) An extension of the local
process in the throat was more frequent than after employment of anti-
toxin. (5) Secondary laryngeal diphtheria could not be prevented with
certainty. Herzfeld concludes that ordinary horse serum should be used
only in the mildest cases in adults, which, as Feer remarks, can be treated
without serum. In faucial diphtheria of any severity and in laryngeal
diphtheria the use of antitoxin is imperative.

Birk states that a severe epidemic of diphtheria in Kiel, during the
• winter of 1918, gave him an opportunity for testing Bingel's claims. He
found that cases sent to hospital wrongly certified to be sufi'ering from
diphtheria and injected with ordinary horse serum subsequently contracted
diphtheria after admission to a diphtheria ward, an occurrence quite
unknown when antitoxin had been given in cases of mistaken diagnosis.
Birk therefore concludes that ordinary horse serum does not possess any
immunizing properties.

H. Meyer, assistant at the Greifswald University Children's Clinic,
injected 17 cases of mild faucial, nasal, and laryngeal diphtheria with

DIPHTHERIA 20

ordinaiy horse serum, using |-10 c.c, an amount corresponding to 1,000-
4,000 units of antitoxin. In three cliildren, who had liad a positive nasal
culture for weeks, but had sliown no other signs of nasal diphtheria, the
treatment had no etiect. Four cases which showed no improvement after
ordinary serum, and in one case distinct spread of the membrane, were given
antitoxin, when immediate improvement occurred. On the other hand, one
case had a relapse after antitoxin which promptly subsided after injection
of ordinary horse serum, and in the remaining nine cases ordinary horse
serum seemed eftective. They were, however, all mild cases which might
have recovered without serum at all. Meyer concludes that ordinary serum
has a certain curative action due to its foreign protein content, but by no
means comparable to that of antitoxin.

P. Aaser, Superintendent of the Ullevaal Fever Hospital for 25 years,
has carried out, with the support of the Nansen Fund, a long series of
investigations on guinea-pigs with a view to controlling Bingel's figures
and conclusions. Owing to a comparative shortage of guinea-pigs, and in
order to check accurately the effect of normal and diphtheria serum, intra-
instead of sub-cutaneous injections of diphtheria toxin were given, according
to the method devised by Schick for the titration of diphtheria antitoxin.
It was found that the amount of toxin required to provoke necrosis of the
skin at the site of injection was strikingly constant ; doses less than this
amount gave rise either to no reaction or only to a pink infiltration of the
skin. As the necrosis could be easily detected, the injected toxin was
limited to the amount required to provoke necrosis. The toxin used had
been stored since 1906 and belonged to the stock used for the titration of
diphtheria serum.

As Aaser 's tables show, an intracutaneous injection of an emulsion of
diphtheria bacilli induced a reaction which, within 24 hours, was indicative
of incipient necrosis (anaemia of the centre of the infiltrated area). After
42 hours complete necrosis was established. Practically the same reaction
occurred when 0-2 c.c. of normal horse serum was added to the emulsion of
diphtheria bacilli, the only marked effect of this addition being the delay
of the necrosis by about 24 hours. Only in a few cases in which very
large doses of normal serum were added, was the necrotic action of the
emulsion inhibited. But when an equal (|uantity of diphtheria serum was
added to the emulsion there was hardly any reaction after 24 hours, and
there was no necrosis. Complement fixation tests also showed that no
specific amboceptors were demonstraljle in normal serum.

Aaser suggests that Bingel obtained no better results with specific
than with non-specific serum because his dosage in both cases was far too
timid. Bingel's average mortality was about 10 per cent., and in 1913 it
was even lo-l per cent. The mortality from diphtheria in Christiania in
the period 1895-1919 was about 5 per cent., and during the last six years
it was only 3-08 per cent., althougli there were many severe cases, and the
disease was classified as diphtheria only when it gave rise to clinical
symptoms. Aaser expresses amazement over Bingel's dosage ; of the cases
terminating fatally within 30 hours of admission, several received only
2,000 or 3,000 units, and only in one such case were as many as 10,000
units given. One child with descending diphtheria was given only 1,000
units. In another case of gangrenous diphtheria, admitted on the second
day, and terminating fatally on the fourth day, only 5X)00 units were
given. Bingel appears also seldom to have repeated an injection. The

30 REVIEWS

frequency with which Bingel's patients developed paralysis also suggests
that insufficient antitoxin was given.

Wood states that during the last six years a combined method of
injecting devitalized Klebs-Loeffler bacilli and antitoxin has been used in
the treatment of diphtheria by the Chicago Department of Health, If the
treatment can be administered before the disease has progressed more than
four days, the initial dose of tlie vaccine is 300 million bacilli. If the
disease has lasted longer than four days, 100 million bacilli should be given,
and from 3,000-5,000 units of antitoxin according to the severity of the
case. The next dose may be increased to 300 million bacilli, and later to
500 million, and the antitoxin may be repeated as indicated. By this
means both destruction of the bacilli and neutralization of the toxin are
effected. Wood also claims that the method prevents the occurrence of
carriers by destroying the bacilli in the throat. Another advantage of the
method is the saving of expense in the cost of antitoxin.

Brownlie treated 50 diphtheria carriers with vaccine in doses ranging
from 10 to 200 millions. The vaccine was prepared in the ordinary way
and was not autogenous. One to eight injections were given. In the
majority a limited number was efficacious. It was found that the vaccine
produced well-defined degeneracy in the morphological appearance of the
cultured organism, followed by its complete dispersal from the locality
invaded. 44 of the cases which had received at most three doses were
discharged with two consecutive negative cultures on the eleventh day.
No bad effects were observed from the use of the vaccine.

Eraser and Duncan report three cases of diphtheria carriers successfully
treated by detoxicated vaccines.

As illustrating the remarkable disinfectant properties of Dakin's
solution, Haugseth records the case of a man, aged 48, who was operated
on for an umbilical hernia. The wound became septic, its base necrotic, and
its margins red and infiltrated. This condition did not affect the tempera-
ture or the patient's general health, but, on the other hand, it was entirely
refractory to ordinary disinfectants, including hydrogen peroxide, silver
nitrate, and potassium permanganate. No improvement having been
effected after four weeks, irrigation with Dakin's solution was adopted
with strikingly rapid effect, and the temperature, which had been about
37°, fell to 36° on the day after the institution of this treatment which was
discontinued after a week. Thougfh no bacteriological examination was
made, diphtheria was diagnosed on the strength of the development of
undoubted polyneuritis.

Aaser, E. Om difterihjertet og dots behandling. Tldssla'.f. d. norsJcc Ldegefor.,
1920, 40, 585-93 ; 617-25.

Aaser, P. Om behandling av difteri med nornialt hesteserum. Tidss7a\ /. d.
norsU Laegefor., 1920, 40, 473-88.

Abmand-Delzi.i.e, p. p. Importance des doses suffisamment elevees dans la
serotherapie de la diphterie par voie intramusculaire et sous- cutanea. Bull, et
mem. Soc. med. d. hop. de Par., 1920, 3^ ser., 44, 380-2.

ABMAND-DEI.II.I.E, P. P., et Mabie, P. L. Etude de I'immunite diphterique
par rintradermo-reaction a la toxine diphterique [Technique de Schick, Park
et Zingher). Ses applications a la prophylaxie scolaire de la diphterie. Bidl.
Acad, de med., 1920, 3^ ser., 83, 530-2.

DIPHTHERIA 31

Baueb, E. L. a preliminary report of Schick testing and permanent immu-
nization ji<?ainst diphtheria in three thousand chikh-en. T/ierap. Gas., 1920, 3rd
ser., 36, 457-()l.

BiEBEB, W. Untersuchungen fiber die Schutzwirkung des Behringschen
Diphtherieschutzmittels T. A. in der Praxis. Beutschc mcd. Wc/mschr., 1920,
46, 1184-7.

BiNOEi.. Zur Behandhmg der Diphtheric mit gewOhnlichem Pferdeserum.
Deutsche med Wchnschr., 1919, 45, 739-40.

BiBK, W. f ber Behandlung der Diphtheric mit gewOhnlichem Pferdeserum.
Med. Klin., 1919, 15, 890-1.

BZ.AT7, A. I. The Schick test, its control and active immunization against
diphtheria. X. York M. J., 1920, 112, 279-82.

BoiDiir, L. Angine diphterique a rechutes multiples et subintrantes. Bull, et
mem. Soc. mcd. d. hop. de Par., 1920, 3© ser., 44, 747-9.

BBOWNI.IE, J. L. The problem of the 'positive throat' in diphtheria con-
valescents. A clinical study of fifty consecutive vaccine-treated cases. Lancet,
1920, i, 706 -S.

Cabtesegna, M., e Casassa, A. Sulla presenza di bacilli difterici nel-
r urina. (Horn. d. r. Acad, di mcd. di Torino, 1919, 82, 424-4G.

DuBOUBG et GuEiTABD, F. La mortalite par diphterie pendant trente ans
a rhopital des enfants assistes a Bordeaux. J. de mcd. de Bordeaux, 1920, 91,
83-6.

Fbaseb, a. R., and Dttncait, A. G. B. Treatment of diphtheria carriers with
detoxicated Ivlebs-Loefiler vaccine. Lancet, 1920, ii, 994-7.

GOPPEBT, F. Zur Nabeldiphtherie bei Neugeborenen. Deutsche mcd. Wchnschr.,
1920, 46, 324.

HAX7GSETH, K. Dakin's v£eske ved saardifteri. Norsk Mag. f. Laegevidensk.,
81, 994-5.

Henkel, M. Zur Nabeldiphtherie bei Neugeborenen. Deutsche med. Wchnschr.,
1919, 45, 1411-3.

Hebzfeld, E. Ueber die Behandlung der Diphtherie mit Pferdeserum.
Miinchen. med. Wchnschr., 1919, 66, 954-8.

Hesse, W. Ein auscultatorisches Philnomen bei Kehlkopfdiphtherie. Mitnchcn.
med. Wchnschr., 1919, 66, 928-9.

HuNTEMULiiEB. Beitrag zur Epideniiologie und Bekampfung der Diphtherie.
Deutsche med. Wchnschr., 1919, 45, 964-6.

jANSSExr, H. Ein Fall von primarer Munddiphtherie bei einem Saugling.
Ztschr.f. Kindcrh., 1919, 24, 179-82.

Keb, C. B. Infectious Diseases. A Practical Textbook, 1920, Second Edition.

Ebomayeb, E. Diphtherie der Vulva bei Erwachsenen unter dem Bible des
Ulcus molle. Dcrmctt. Wchnschr.. 1920, 71, 770-2.

Lambebt. Manifestations anormales de la diphterie en oto-rhinologie. Arch,
mcd. beiges, 1920, 73, 382-92.

De Lavebgne. De I'alteration du liquide cephalo-rachidien dans les paralysies
diphteriques du voile du palais et a tvpe de polynevrite. Bull, et mem. Soc. med.
d. hop. de Par., 1920, 3© ser., 44, 1246-50.

33 REVIEWS

De Lavebone et Zoelleb. La diphtherino-reaction (Reaction de Schick)
dans les paralysies jwst-dipliteriques. Bull, et mem. Soc. med. d. hup. de Far.
1920, 3e ser., 44, 954-6.

IiEEN-DEBTZ, G. Pi'imare Vaginal- und Hautdiphtherie niit postdiphtherischen
Lahmungen. Med. Klin., 1920, 16, 151-2.

Leete, H. M. The Schick reaction for the determination of susceptibility to
diphtheria. Lancet, 1920, i, 192-4.

Lxi.i.7, T. E. An experience with the Schick test and toxin -antitoxin mixture
and a plea for their use in the extinction of diphtheria. Boston M. 4- S. J.,
1920, 182, 110-13.

LooPT, C. Difteri hos nyfodte. Med. Bev., 1920, 37, 66-74.

Mabbzott, W. M. Postdiphtheritic paralysis of the respiratory muscles :
report of a case treated by prolonged artificial respiration. J. Am. M. Ass.,
1920, 75, 668-9.

Mabtzit, L. Vingt-cinq annees de serotherapie anti-diphterique. Bull. Acad,
de med., 1919, 82, 172-9.

Meyeb, a. H. Difteriinfektion per Bornafdelinger. UgesJc. f. Laeger. 1919,
81, 908-17.

Meyeb, H. Ueber die Behandlung der Diphtherie niit normalem Pferdeserum.
Beutsche med. Wclmsclir., 1920, 46, 1048-9.

Fabk, W. H. The Schick reaction and the immunization of children against
diphtheria: a communication. Med. Bee., 1919, 96, 900.

Peifeb. Diphtherie des Penis und des Nabels. Deutsche med. Wchnschr.,

1919, 45, 1037.

Fbausztztz, p. G, Zur Kasuistik der Nabeldiphtherie des Neugeborenen.
Bed. hlin. Wchnschr., 1919, 56, 797-9.

Henault, J. Sur la diphterino-reaction (Reaction de Schick). Bull. Acad, de
med., 1920, 3e ser., 83, 130-2.

EriEMSCHNEiDEB, G. Zur postdiphtherisclien Hemiplegie im friihen Kindes-
alter. Monatsehr. f. Kinderh., 1919, Orig. 15, 415-24.

E.IEUX et Z01.1.EB. Considerations sur la reaction de Schick en milieu militaire.
Bull, et mem. Soc. med. d. hop. de Far., 1920, 3e ser., 44, 717-20.

RoiiiiESTOir, J. D. (I). Diphtheritic hemiplegia. Clin. J., 1913, 42, 12-14.

I{.OZ.]:.ESTOir, J. D. (2). Transient hemiplegia in diphtheria. Bev. Neurol. 4'
Fsyehiat., 1916, 14, 145-50.

KoitLESTOir, J. D., and Macleod, C. Intramuscular injections of antitoxin
in the treatment of diphtheria. Brit. J. Child. Bis., 1914, 11, 289-97.

ScHONFELDEB, T. Om navledifteri. NorsJc Mag. f. LaegevidensJc, 1920, 81,
857-76.

Simmons, J. S. Virulent diphtheria bacilli carried by cats. Am. J. M. Sc.,

1920, 160, 589-94.

Snei.1., M. Die diphtherische Nabelinfektion mit besonderer Berucksichtigung
der Nabelgangriin. Jahrh. f. Kinderh., 1919, 89, 40-57.

Weili.-Hai.i.e, B. Voie d'introduction et posologie du serum antitoxique dans
le traitenient de la diphterie. Bidl. et mem. Soc. med. d. hop. de Far., 1920,
3e ser., 44, 83-5.

DIPHTHERIA 33

WiETiNO. Wunddiphtherie und Hospital brand. Munchen. med. Wchmchr.,
1920, 67, 262.

"Wood, F. M. The vaccine antitoxin method in the treatment of diphtheria.
N. York 31. J., 1920, 103, 53-4.

J. D. R.
C. L.

INJURY CAUSING SPASMODIC CONTRACTION OF
SEGMENTS OF ARTERIES OF MEDIUM SIZE

The vasoconstrictor nerves supplying the wall of a medium-sized artery,
such as the brachial or superficial femoral, may be irritated by blood extra-
vasated into and around the sheath of the artery whilst the wall of the artery
escapes injury, the endothelial lining of the artery is unaltered, and there is
no thrombosis. But whilst the spasmodic contraction lasts there is a greatly
diminished flow through the segment of the artery affected. A bullet in
traversing the limb passes close by the artery, and there is induced a
spasmodic contraction involving several centimetres. The spasm lasts a day
more or less and then spontaneously disappears. The immediate sign con-
sequent on the restriction of the flow of blood through the segment is the
absence or marked diminution of the circulation through the limb beyond
the injury. This being observed, it may reasonably be assumed that a con-
tusion or laceration of the artery may have been produced, and that there is
a danger of secondary haemorrhage and gangrene. In consequence, the
surgeon proceeds to explore the artery at the site of injury ; in view of the
possibility of conditions to be described, it must not be hastily assumed that
a contused, lacerated, and thrombosed artery exists because there is a defec-
tive circulation in the limb beyond. The condition to be described was
termed by Viannay ' La stupeur art^rielle traumatique ' ; by Fiolle, * L'in-
hibition segmentaire des arteres dans les plaies de guerre (arret du cours du
sang au niveau d'arteres traumatisees sans lesions visibles des parois ni
coagulation) ' ; by Kiittner and Baruch, ' Der traumatische segmentiire
Gefasskrampf '.

There have been numerous observations on the nerve-supply of medium-
sized arteries by the sympathetic. Leriche and Heitz concluded that as soon
as the sheath of the artery containing the sympathetic nerve-fibres is touched
the artery enters into contraction until it has no more than one-third or one-
quarter of its normal lumen in the segment involved in the contraction.
Meanwhile, the artery above and below is not affected. The reaction varies
in degree, being more marked in some animals, less in others. It is a reac-
tion more evident in the brachial than in the axillary or subclavian arteries,
more active in the femoral than in the iliac arteries, in the brachial even
more than in the femoral.

Viannay describes the following cases :

Case I. A fragment of a bullet had entered the nape of the neck at
the level of the 6th cervical spine and a little to the left ; it had crossed the

IV. D

34 REVIEWS

subclavian fossa and made exit through the anterior border of the axilla.
There followed a large haematoma in the axilla and a loss of pulsation in all
the left upper extremity. An incision was made along the free border of
the pectoralis major, and next the muscle was cut across up to the clavicle.
After turning out the clot the axillary artery and vein were found not to be
wounded. The clavicle was then divided by excising a length of 5 cm.
which exposed the subclavian artery on the first rib. It appeared uninjured
but small, with a feeble pulsation, whilst there was no pulse at the wrist.
The wound was sewn up with a drain, and a few hours later a pulse • could
be felt in the radial artery which increased until quite restored.

Case II. A fragment of shell passed through the back of the upper
part of the arm, crossed the axilla and entered the chest. There was severe
primary haemorrhage, the radial pulse was weak and irregular. Five hours
after the injury the termination of the axillary and the commencement of
the brachial arteries were exposed ; the axillary artery pulsated well, the
brachial at its commencement was very small, and the pulse in it could
hardly be felt. The next day the radial pulse and circulation in the upper
extremities were equal on the two sides.

Case III. A bullet had caused a small wound in the forearm with
marked contusion, and there was no pulse at the wrist. On exposing the
radial under the wound, the artery was found intact, but there was no
pulsation in it for 4 cm. There was slight ecchymosis in the adventitia of
the artery. The affected segment was excised, after which both ligatured
ends pulsated, and there was a good recovery. No lesion could be found in
the segment of the artery excised.

La Coste and Ferrier published a case in which they made observations
on the blood-pressure of the injured limb. A fragment of shell had passed
across the apex of Scarpa's triangle, and the pulse at the ankle below was
scarcely perceptible. The superficial femoral was exposed, but found
uninjured ; the circulation in the injured limb had become the same on
the opposite side by the second day as shown in the following table :

Time.

Right.
The Injured Li

mb.

Left
The Uninjui

ed Limb.

Hrs.

Mins.

Max.

Min.

Ampli-
tude.

Max.

Min.

Ampli
tude.

Before operation

After operation

J5 >)

5) )>

Next day

:? T?

Second day

5> >J

Viannay described also a case which was not the result of a bullet
wound. A mechanic, wliilst starting the motor of an aeroplane, was struck
by a blade of the propeller on the inner side of the right arm a little above
the epitrochlea. It caused a small transverse wound prolonged by a linear
ecchymosis ; there was little external haemorrhage. There was found a
marked diminution of the radial pulse below the injury. The margins of the
wound were first excised ; there was then exposed a small rupture of
the aponeurosis, below which the tip of the epitrochlea was bare but not
fractured. On dividing the expansion of the biceps the median nerve was

INJURY CAUSING SPASMODIC CONTRACTION, ETC. 35

found intact. The sheath of the brachial artery was slightly infiltrated
with blood ; the artery at first sight seemed not to pulsate ; on close
examination a very feeble pulse was evident. On opening the sheath
there was no apparent wound of the artery oi* of the venae comites, the
wall of the artery being, perhaps, slightly more bluish tlian normal. The
wound was sutured without a drain and healed without complication.
The following observations were made on the blood-pressure :

Eight.
The Injured Limb

Max.

Min.

Before operation

2 hours after oper
16 „
18 „

alioii

8
9
7
6

Left.

The Uninjured Limb

Max.

Min.

Within the next day or two the maxima became definitely equal, but
the minima remained unequal until the fourth day.

Fiolle's case furnishes an instance of the importance of distinguishing
the condition. In a man aged 21 the bullet entered by the left buttock,
crossed Scarpa's triangle and lodged in the scrotum. There was found a large
haematoma in the triangle, over which the skin was violet and tense ; there
was no pulsation, neither in the triangle nor in the limb below, A free
incision was made, which exposed the common femoral artery as it emerged
from under Poupart's ligament, and the loop of a ligature was passed under
it. Then the haematoma was incised and the clot turned out ; also a wounded
vein was ligatured. The bullet had crossed the commencement of the super-
ficial femoral artery ; the common femoral above pulsated well and was of
full size ; the superficial femoral appeared very small, there was no pulsation
in it, it was supposed to be thrombosed. Thereupon 3 cm. of the commence-
ment of the superficial femoral was cut out ; the excised segment exhibited
no thrombosis, or injury to the inner or outer coat. Profuse suppuration
followed in the wound ; on the 7th day there was severe secondary haemo-
rrhage from the common femoral arter3^ and a ligature was applied just
above the sloughing opening and below Poupart's ligament. The next day
further haemorrhage was followed by death, when suppuration and sloughing
were found to have extended to the external iliac arteiy.

In Kroh's first case of a revolver shot in the groin there was no pulse in
the superficial femoral artery. The saphena vein had been cut across at its
junction with the femoral. The superficial femoral artery, when first found,
seemed reduced to the size of a packing-needle. After exposing 5 cm. of the
artery, dividing the sheath, which was infiltrated by blood, and watching it
for five minutes, it was seen to gradually enlarge and pulsate more strongly,
next the popliteal artery began to beat, and a pulse was felt in the internal
plantar artery.

In a second case, in which a bullet had crossed the artery in Scarpa's
triangle, there was no pulsation in the popliteal artery or in the arteries of
the foot, and the skin of the limb below the knee was a yellowish-white.
The pulse above the site of injury and in the opposite limb was good. After
nine hours the injured limb had become warm and a bright red ; the arteries
in the foot pulsated well. The wound healed without complications.

In a third case of a wound in the arm, following which the forearm and
hand had become yellowish- white and bloodless, the brachial artery for

D 2

36 REVIEWS

lOj em. above the elbow-joint was, on exposure, found to be contracted
to a thread and pulseless, whilst above it pulsated strongly. After prolonged
gentle stroking with the finger the artery slowly dilated to its normal
dimensions, and the forearm and hand presented the most marked arterial
hyperaemia. The radial pulse afterwards became equal on the two sides
and the wound healed without disturbance.

Kuttner and Baruch claimed to have met with 8 cases of what they
referred to as a waist-like spasm of a segment of an artery. In 6 the
operation gave an opportunity for an exact observation ; in the remaining

2 the clinical picture appeared definite.

Case I. Among other slight wounds by shell fragments one entered to
the outer side of the tendo Achillis, just above the os calcis, and made exit by
a larger and irregular wound between the tendo Achilhs and the internal
malleolus ; there was only venous bleeding and no bone injury. Four hours
after the injury, after excising the margins of the two wounds, the exposed
posterior tibial artery was found not to pulsate, so 2*5 cm. was excised, after
which both the ligatured proximal and distal ends pulsated. On examina-
tion the excised segment showed no thrombosis or injur}- to the intima ;
only at one point was the adventitia infiltrated by blood.

Case II. A fragment of shell entered the outer side of the left thigh
about its middle and made exit on the inner side about the same level with-
out fracturing the femur. Much blood had been lost, the limb was of a pale
livid colour; there was no pulse in the dorsalis pedis and posterior tibial
arteries ; the man could not move the limb. Five hours later a large amount
of clot was turned out ; the femoral vein had been ruptured, its ends had
retracted, and each bled freely before being tied. The sheath of the artery
was infiltrated by blood and it did not pulsate. After the artery had been
exposed for 10 cm. it was noted that a length of 2-5 cm. was contracted and
at first sight pulseless ; above the artery pulsated, below there was no pulsa-
tion. On more careful examination a small pulse was detected in the
contracted portion. Immediately after closing the wound no pulse could be
felt in the foot ; after a while a pulse was felt, then it was not felt, and again
the pulse returned. Three hours after the operation the pulse in both feet
was normal and there were no further complications.

Case III. A shell fragment entered the back of the arm ; the wound
of exit was large, just external to the internal bicipital sulcus at the same
level. A tourniquet having been applied, there was much swelling below
and all the arm nerves were paralysed when the tourniquet was removed,
four hours after the injury. There was then no external haemorrhage, but
the radial pulse could not be felt. The bracliial vein had been torn across,
also the median nerve lacerated. The brachial artery for the length of

3 cm. did not at first sight seem to pulsate, but on careful observation a small
pulse was found passing through the segment. The arm after the operation
was somewhat Uvid ; the pulse the next day could be felt at the wrist, but
was weaker than on the uninjured side ; the second day the pulses on the
two sides were equal.

Case IV. A very similar case to the last exhibited a cold bluish arm
without movement and with an absence of a radial pulse ten hours after the
injury. The ruptured portion of the basilic vein was cut out ; there was no
injury to nerves ; the appearance of the artery was the same as in Case III.
Twenty-fours later the limb was warm and of a good colour, with the radial
pulse equal on the two sides.

INJURY CAUSING SPASMODIC CONTRACTION. ETC. 37

The gi-eatest difficulty in diagnosis arises in relation to the popliteal

artery-
Case V. A machine-gun bullet entered to the inner side of the knee
and made a larger wound of exit on the outer side ; there was no sign
of fracture or of a haematoma, but of an acute efiusion into the joint. The
foot and leg were cold, bluish, and quite immobile ; there was no pulse in the
dorsalis pedis or posterior tibial arteries. The leg was raised and wrapped
up ; four hours later a weak pulse was felt in the posterior tibial, but the
limb was still cold and motionless. On the next day the dorsalis pedis could
be felt pulsating ; after 48 hours the circulation had recovered, the foot and
toes could be moved, and subsequently the knee. Whilst under observation
for the month following there was no sign of a haematoma or of an
aneurysm.

Case VI. A rifle bullet traversed the thigh about its middle from the
anterior aspect to the inner side behind. There was free primary haemo-
rrhage, much swelling of the thigh, the leg and foot were cold and immobile.
Ther'e was no pulse in the dorsalis pedis or posterior tibial artery. The
circulation generally was weak owing to shock. The limb was elevated and
wrapped up, and after the general circulation had improved the posterior
tibial artery of the injured limb could be felt, the leg became warm and the
toes moved. Meanwhile, the swelling of the thigh did not increase. The
man was three weeks under observation, during which there were no com-
plications and the wound healed.

Case VII. A fragment of shell caused a wound of entry the size
of a pfennig to the outer side of the right knee-joint, and a wound of exit
the size of a mark in the popliteal space. The man was picked up after ten
hours and operated upon eighteen hours from the injury. The leg and foot
were pale, cold, and insensitive, the foot could not be moved, the calf muscles
were hard but the calf was not swollen, there was no pulse in the posterior
tibial artery. An incision was made into the calf for a suspected haema-
toma ; none was found, but as no artery spurted the limb was amputated
through the knee. The popliteal artery, the vein, and both nerves were
found intact, only the sheath of the artery was widely infiltrated by blood.
There was no haematoma in the popliteal space.

Case VIII was an instance of spasm affecting the common carotid
artery. A bullet had passed through the neck from the anterior border of
the right sternomastoid muscle at the level of the larynx to a point three
fingers' breadth to the right of the 6th cervical spine. The man walked back
complaining of pain in the right side of his head and dark patches before
the right eye. There was no haematoma, but a thrill could be felt and
a bruit heard. The artery was exposed six hours after the injury ; there was
a small hole in the internal jugular vein which was closed ; the common
carotid artery was quite intact, but for 3 cm. it was contracted to the size of
a goose-quill, through which there was a small current with a thrill.
Beyond this no pulsation was felt ; on the proximal side there was evident
pulsation. No complications arose; a fortnight later no thrill was felt or
bruit heard.

The two cases described by Frassi direct attention to the danger of
stroking the contracted segment, for although it may not appear thrombosed
there may still be injury to the internal coat. The stroking may then in-
duce the formation of a clot and push it onwards, so causing gangrene. A
man was shot throngh the popliteal space, and the limb below was pulseless.

38 REVIEWS

The popliteal vein had been lacerated, the popliteal artery was intact
but contracted and with a very slight pulsation, until after stroking down-
wards, when the pulsation returned to its full extent. But the leg went
gangrenous and had to be amputated. In the second case there was an
absence of pulsation in a segment of the radial artery, above which the
artery pulsated well. After gentle stroking of the artery the pulsation
returned in the contracted segment. Gangrene ensued, and the limb was
amputated.

FioiiXiE, J. L'inhibition segmentaire des arteres dans les plaies de guerre.
Bull, et mem. Soc. de cliir. de Far., 1918, 44, 996.

Fbassi, L. L'inibizione segmentaria delle avterie secondaria a ferite. Os^,
maggiore, 1920, 4, 66. {Zentralbl. f. Chir., 1920, 47, 1402.)

Eboh, p. Frische Schussverletzungen des Gefiissappavates. BcHr.z.Min.Chir.,

1917, 108, 61.

EuTTNEB, H„ u. Babuch, M. Der traumatische segmentiire Gefasskrampf.
Beitr. s. Jdin. Chir., 1920, 120, 1.

La Costs et Febbieb. Un cas de stupeur arterielle. Bull, ct mem. Soc. de
chir. de Par., 1918, 44, 1323.

Lebiche, R., et Heitz, J. Des effets physiologiqiies de la sympathectomie
peripherique (reaction thermique et hypertension locale). Compt. rend. Soc. de
hiol, 1917, 80, 66.

ViANNAY, C. (1). La stupeur arterielle traumatique. Presse med., 1919, 27,
106.

ViAHNAY. C. (2). La stupeur arterielle. Bull, ct mem. Soc. de chir. de Par.,

1918, 44, 322.

W. G. S.

NON-TUBERCULOUS JUVENILE COXALGIA

Before the use of X-rays for diagnosis, all pain in the hip of young
people was presumed to be tuberculous in nature, even what were popularly
called ' growing pains '. By the aid of the X-rays changes at the epiphysis,
the separation of the head and the bending of the neck, producing the
deformity of coxa vara were distinguished. In June 1909, A. T. Legg described
to the American Orthopoedic Society, 5 cases of what he termed ' an obscure
affection of the hip-joint '. He appears to have differentiated the cases from
tuberculous disease, as there was no tendency to caries, caseation, and sup-
puration, but he did not sharply separate them from the epiphj^seal changes
for the recognition of which the use of the X-rays are essential, and which
are in many cases, associated with rickets, early or late. Legg's cases were
between 5-8 years of age, lameness had followed slight injur}'', resulting
in thickening of the neck of the femvir with little or no pain, no constitutional
symptoms, little or no spasm of muscles, and no shortening.

Coxalgia being generally understood to refer to an early stage of
tuberculous hip-joint disease, the term pseudocoxalgia has been adopted by
some to denote the non-tuberculous disease.

NON-TUBERCULOUS JUVENILE COXALGIA 89

In 1910, Calv(^, among 500 cases at Berck, distinguished 10 cases of
chronic or subacute arthritis of the hip-joint, of short duration, recovering
witli a mobile joint. The cases were fully distinguished by means of X-rays ;
the skiagrams reproduced tended to show that the changes from the normal
connnenced in the nucleus of ossification of the head. The normal condition
of the ossifying head is that of a hemisphere, slightly concave towards the
neck from which it appears separated by a translucent line. In the cases
referred to it was found changed to a flattened cap, the epiphyseal line
irregular, and the neck of the femur thickened. In young children the
nucleus of ossification appeared subdivided, the particles later fusing to
form a flattened head. But there was an absence of ex'osion of cartilage or
bone.

An appropriate comparison maybe made between Calvd's communication
and that from the same hospital at Berck 10 years later by Sorrel. Using
the term ' Infantile deforming osteochondritis of the upper epiphysis of the
femur ', Sorrel distinguished 6 among 1,500 children with hip-joint disease,
in which the following changes were noted by the X-rays. In the very
young the nucleus of ossification of the head appears divided into two
or three unequal bits. The head resembles a flat cap. As the separate
parts fuse together, the head tends to mushroom out ; its process of ossifica-
tion is irregular, opaque zones are intermingled with translucent areas.
The epiphj'seal cartilage is irregularly indented, or divided by irregular calci-
fication. The articular line as seen in the radiographs is increased ; Sorrel
attributed this to distension of the capsule by fluid. The overhanging
curve of the acetabulum presented in some cases irregularities, but he
attributed little importance to this point. Sorrel also included changes in
the neck of the femur giving rise to slight degrees of coxa vara or coxa valga.
The report on Sorrel's communication by Mouchet and the discussion
on it by Lapointe and Mauclaire whilst clearly distinguishing the cases
from tuberculous disease, appear to draw no sharp distinction between the
changes commencing in the nucleus of ossification of the head and those
at the epiphyseal line, causing deformity of the neck.

Fairbank's description of a case follows that by Calv^, and he uses
the terms Pseudocoxalgia — Osteochondritis deformans juvenilis, i. e. non-
tuberculous pain in the hip-joint in which the head of the femur becomes
deformed owing to disturbance in the nucleus of ossification.

Perthes, in 1910, described the affection under the name of arthritis
deformans juveniHs, the change being regarded as similar in its commence-
ment to the osteoarthritis of tlie hip of old people, a malum coxae juvenile
resembling mahon coxae senile, but only advancing a little way and then
undergoing spontaneous arrest.

Foui' illustrations from the post-mortem examination of a case by
Pommer are reproduced by Kreuter. In this instance there was found
a fibrillation and erosion of the articular cartilage covering the head, which
had commenced just above the insertion of the ligamentum teres. Also
similar changes had occurred on the opposing surface of the acetabulum.
From this point of view the pathological changes of the articular surface
stop short at a flattening of the head and a widening of the acetabulum and
do not advance to a porcellaneous condensation of the exposed bone, or to
osteophytic formations at the margins of the acetabulum.

Sundt's monograph deals with every aspect of the disease. The term
' Osteochondritis ' is rejected because there appears to be no inflammatory

40 REVIEWS

element in the disease, and the cumbersomeness of the term Calvd-Legg-
Perthes is minimized by the contraction C. L. P. Sundt's material consisted
of 66 cases, most being sent to the Fredriksvern Coast Hospital for scrofula
with the diagnosis of tuberculosis of the hip, A large section of the mono-
graph is, accordingly, devoted to the differential diagnosis of these two
conditions, and Sundt is driven to admit that, apart from abscess formation
and other signs of destructive processes pointing unmistakably to tubercu-
losis, there is no one pathognomonic sign which by itself can distinguish
one disease from the other. It is, therefore, not surprising to find that
many of his cases were treated by immobilization for a considerable period
before the non-tuberculous character of the disease was established. This,
by the way, appears to be an error in the right direction, for Sundt has
come to the conclusion that it is a far more serious mistake to diagnose and
treat tuberculosis of the hip as a case of C. L. P. than vice versa.

Sundt finds that heredity, trauma, sex (male) and age (childhood)
play important parts in the aetiology of this disease, whereas syphilis and
tuberculosis are not contributory factors. In 110 cases of C. L, P. in which
v. Pirquet's reaction has been recorded, only 37 gave a positive reaction.
With regard to treatment, Sundt has come to the conclusion that the less
these patients are interfered with the better. He justifies this attitude by
the results of classifying his cases according as they were treated for long
periods or for short spells by immobilization, or not treated at all. In 19 of
his cases the limb was immobilized as for tuberculosis for a period of 1 to 4
years. In another series of 16 cases, relief of pressure on the hip or absolute
immobilization was maintained for an average period of 6 to 7 months. In
the last series of 23 cases observed for periods of 9 months to 12 years, the
principle was adopted of letting the child run freely about and abstaining
from every interference. A comparison of the ultimate results showed no
differences in these three series to indicate that progress of the disease
could be arrested by treatment or, on the other hand, that its course could
be favoured by giving the child perfect freedom. Sundt is convinced that
C. L. P. is an exceedingly common disease in childhood, that abortive forms
occur frequently, and that many a case of transient limping in childhood
may subsequently be proved to be a case of C. L. P. as shown by skiagrams
taken in adult life.

From the numerous references to this obscure affection which have
appeared of late, it would seem that injury, even slight injury, has only
been noted in a few and, besides, the affection has often been bilateral ; it
has been described as following the reduction of a congenital dislocation,
but it has also been seen on the opposite side to a unilateral congenital
dislocation. One might interpret that observation as showing a congenital
cause, but it is also possible to attribute it to the extra stress thrown on the
sound side by the unilateral dislocation. A mild infection has also preceded
the trouble.

The provisional conclusion on this obscure affection of the hip-joint
would seem to be that it occurs particularly in the class of children specially
liable to tuberculous disease ; that it is best treated for a while in the same
way as early tuberculous disease until by repeated X-ray examinations this
latter assumption can be disproved, when the child should be let run about
under observation. Granted the correctness of the diagnosis, it may be
expected to make a complete recovery.

Such complete recoveries would seem to be the rule when the probable

NON-TUBERCULOUS JUVENILE COXALGIA 41

underlying cause, malnutrition, is at the same time overcome by good food
and fresh air. But when the changes on the articular surface have been
probably secondary, whether to rickety disturbance at the epiphyseal line
resulting in coxa vara, or when occurring on the opposite side to a unilateral
congenital dislocation, or when preceded by some infection, then there may
well be permanent limitations of movement.

CAI.VE, J. Sur une forme particuliere de pseudocoxalgie greffee sur des deforma-
tions caractt-ristiques de I'extremite superieure du femur. Rev. de chir., 1910,
42, 54.

Paibbank, H. a. T. Pseudocoxalgia — Osteochondritis deformans juvenilis.
Lancet, 1920, i, 20.

Kbeuteb, E. Zur Atiologie und Pathogenese der Osteochondritis deformans
juvenilis coxae. Zentralbl f. Chir., 1920, 47, 1162.

Lego, A. T. An obscure affection of the hip-joint. Boston M. ^- S. J., 1910,
107, 111.

Febthbs, G. (1). Ueber Arthritis deformans juvenilis. Deutsche Ztschr.f. Chir.,
1910, 107, 111.

Perthes, G. (2). Beitrag zur Atiologie der Osteochondritis deformans.
Zentralbl. f. Chir., 1920, 47, 542.

SoBBEL, Etienne. Osteocliondrite deformante infantile de I'epiphyse superieure
du femur. Bull, et mem. Soc. de chir., 1920, 46, 1421.

SuxTDT, H. Undersokelser over Malum Coxae Calve-Legg-Perthes. Jacob
Dybwad, Christiania, 1920, pp. 231.

W. G. S.
C. L.

ANTERIOR DISLOCATION AT THE ELBOW

There has been doubt as to the occurrence of an anterior dislocation at
the elbow. Until the observation in 1914, by Theodore Kocher of a case at
the Surgical Khnik in Bern, and a second case of the kind by his son in 1916,
no previous assertion has received confirmation by X-ray examination.

Case I. A man, aged 40, was carrying a box weighing 25 kilos upstairs
upon his right shoulder, the right arm flexed at the elbow supporting the
box on that side, and his left hand on the other side. The box struck
against a low ceiling, and he fell on liis knee ; as he got up the box slipped
otf his shoulder to the right, backwards ; this forcibly extended his right
arm, and twisted it outwards at the elbow. The pain thus caused made
him fall to the ground with the box on the extended elbow. Some hours
later he was examined, when the forearm was found fixed at a right angle
with the humerus, abducted, and semipronated. The lower end of the
humerus, including the external condyle, capitellum, and trochlea, but not
the internal epicondyle, could be felt behind. In front could be felt the

42 REVIEWS

olecranon with the sigmoid notch and coronoid process ; external to this
was the head of the radius in normal relation with the ulna.

The tense biceps and brachialis anticus were partly ruptured, also the
triceps. X-ray photographs showed the ulna and radius dislocated in
front of the humerus, the head of the radius being displaced upward
1-5 cm., and the olecranon process 4*5 cm. The internal epicondyle had
been fractured and displaced in front of, and internal to the coronoid process of
the ulna. 26 years before, at the age of 14, the patient had fallen on the elbow
and broken off a bit of bone, possibly the internal epicondyle. Attempts
at reduction failed until, when the man was fully anaesthetized, the forearm,
flexed to a right angle at the elbow, was pushed backwards and towards the
inner side so that the olecranon passed under the inner condyle and was
then pressed outwards into place, the radius following.

The patient recovered use of the arm, but could not completely extend
or flex the elbow, being prevented hy the detached internal epicondyle which
he refused to have excised.

Case II. A man, aged 21, fell 7 metres down through an opening in
a hay loft upon his left side, and in doing so struck his left elbow against
the edge of the opening. He sustained, together with a fracture of the
ilium, a dislocation forwards at the elbow, combined with a fracture of the
olecranon. When examined the elbow was much swollen, the forearm
fixed at an angle of 120° with the arm, midway between pronation and
supination. The whole limb seemed shortened and the forearm displaced
a little outwards. There could be felt the tip of the olecranon in its
normal position with a sharp edge, also the head of the radius could be
felt in front of the external condyle. The X-ray photograph showed
a displacement of the ulna and radius in front of the humerus and some-
what outwards, except for the tip of the olecranon remaining attached
to the triceps. The dislocation was reduced under general anaesthesia
by forcibly flexing the forearm on the arm and pushing backwards, and by
exerting direct pressure upon the head of the humerus.

Among some 25 cases in which this accident is said to have occurred,
that published by Richet in 1839, had additional evidence supplied by
a post-mortem examination. A man, aged 18, fell 14 metres from a scaffold
and apparently sustained an injury to the elbow the same as in Case II
above. Reduction (needless to note without a general anaesthetic) was made
by extension on the forearm and counter-extension on the arm, then sharp
flexion and pushing the forearm backwards. The displacement tended to
recur and the elbow was fixed by plaster. Death followed from other
injuries, when the brachialis anticus and the muscles arising from the
internal condyle were found ruptured, the internal lateral ligament torn,
and the olecranon fractured obliquely.

A. Kocher concludes that the dislocation is due to torsion so that the
external or internal lateral ligament is ruptured, and the forearm screwed
round the external or internal condyle whilst fully or over-extended at the
elbow. Then the internal or external lateral ligament gives way, or the
internal epicondyle is torn off. In the more severe cases there is a fracture
of the olecranon process ; in that case the dislocation forwards could occur
in acute flexion.

In connexion both with dislocations and fractures at the elbow, Kirmis-
son recalls Malgaignd's view that the common dislocation backwards at the
elbow occurs in extension, or with only slight flexion, combined with torsion.

ANTERIOR DIST.OCATION AT THE ELBOW 43

There is thus agreement as to tlie importance of torsion in both
instances, in the case of the very rare, as in that of the common
dislocation.

KxBMissON, E. Considerations gonerales sur le mecanisme des fractures
de I'extremite inferieure de I'humerus et des luxations du coude. Hev. d'orthop.
1918, 5, 1.

EocHEB, A. Die Luxatio cubiti anterior. Erqehn. d. Chir. it. Orthop., 1918,
10, 1122.

W. G. S.

THE PHYSIOLOGY OF PAIN

Pain is so common, in fact so universal an experience, that it is apt to
be taken very much for granted and to escape any very searching curiosity
as to its ultimate signiticancc.

It is of course true that philosophy has alwa3^s been much occupied
with the problem of pain, but such inquiries have mostly been conducted
upon an assumption, whether acknowledged or not, which makes their value
to the biologist almost negligible.

The object of practically all philosophic speculation has been to
demonstrate some kind of congruity between man's moral nature and the
universe at large. The subject of pain, therefore, has been approached by
the philosopher under the conviction that the phenomenon must necessarily
and however indirectly have value and moaning for mankind. In conse-
quence, we see ascriljed to pain a ' disciplinary ' function in human
experience which enables the philosopher to regard it as a not inconsistent
element in an anthropocentrically constructed universe. Such methods and
conclusions are, however, very unsatisfying to the biologist who is met at
the outset b}'- the fact, so very evident to objective examination, of the
enormous discrepancy between the amount of experienced pain in the world
and any observed physical, mental, or moral benefit that ensues to the
sufferers.

Other methods must be used if results capable of resisting criticism are
to be attained, and it was to these objective modes of inquiry that we were
referring when we suggested that the general significance of pain as a bio-
logical phenomenon had attracted relatively little curiosity.

It is perhaps commonly assumed that pain is to be regarded as an
evidence of disturbance of function similar in its general features to other
such manifestations, and strictly comparable, for example in a broad way,
wnth vertigo, vomiting, wasting, paralysis, and so forth. It is assumed,
that is to say, to be related as to its origin and continuance with so)ne
definite underlying abnormality of which it is a more or less precise ex-
pression and measure. The further assumption is also not infrequently
made that in a general way pain may be looked upon as having a distinct
though perhaps indirect functional meaning and value to the individual, so
that within limits sensitiveness and liability to pain constitute conditions
tending to favour survival.

Consideration, however, shows that these assumptions cannot be
accepted without great reservations, and that pain as a symptom occupies

44 REVIEWS

a position by no means strictly analogous with that, for example, of dyspnoea
or vomiting. Certain peculiarities in the status of pain are not difficult to
detect and they may be indicated in three broadly definable groups. Of
these groups the first is concerned with the frequency of pain, the second
with the relations between pain and its pathological causes, and the third
with the functional value of pain to the individual.

The frequency of pain. — Pain is undoubtedly by far the commonest
disturbance of well-being to which man is subject. Not only is it the
almost universal manifestation of well-defined injury and disease, but it
spreads its range much farther into experience than this. If one watches
oneself carefully, even the healthiest will find that quite apart from injury
he rarely gets through a whole day without some experience of bodily pain,
some usually transient twinge or stab or ache that easily lapses from
a healthy memory because it is unaccompanied by any other evidence of
abnormality.

The relation of pain to its bodily cause. — It is a commonplace of
practical medicine that pain is of all symptoms the one most likely to show
itself persistent and inveterate, and it is perhaps true to say that the more
pain is a predominant symptom the more difficult it is to treat efiectually.
The longer the time during which pain has been experienced the more
difficult it is to relieve, though the originating lesion has ceased to progress
or even been eliminated. It may even be said that when severe pain has
been present for a long time, it seems as it were to become ingrained in the
very substance of the nervous system, and to have become truly ineradicable.

The functional value of pain. — Within the comparatively narrow
limits of recoverable injury, pain undoubtedly has a value for the individual
and furnishes unmistakable guidance whereby the life or the activity of the
patient may be preserved. The value of sensibility to pain in this regard
is very well illustrated by the diseases such as tabes and syringomyelia, in
which analgesia of the limbs is a usual symptom. There can be little doubt
that the so-called neuropathic arthritis of these conditions is due to persis-
tent use of joints under circumstances of slight injury, when in the normal
subject pain would have rendered disuse and rest imperative.

When we consider the usefulness of pain to the individual and to the
species, it soon becomes obvious that a distinction must be sharply drawn
between pain in relation to disease and pain in relation to injury. In
disease pain is almost wholly without usefulness to the sufferer. Apart
from a few exceptional cases, such as perhaps the pain of acute pleurisy
and of caries of the spine, pain is no more than an arbitrary and super-
added affliction. It is difficult to suppose that the pain of cerebral tumour,
of renal or biliary colic, of cancer, of trigeminal neuralgia, has the slightest
functional value to the patient. Moreover, in most cases of cancer pain is
characteristically absent in the earlier stages, and present only at a period
when successful treatment is doubtful or impossible. Again, certain diseases
consist, as it were, entirely of pain ; in trigeminal neuralgia, and the pain
that sometimes follows amputation, the one symptom constitutes the whole
disease and may continue for twenty, thirty, or even, as in one case known
to me, sixty years. Such cases constitute the very acme of the functional
uselessness of pain. A superficial examination then of pain as met with in
practical medicine furnishes a fair body of evidence that its position as
a symptom is remarkable, even perhaps unique. Let us now turn to what
we know of the mechanism of pain in the normal.

THE PHYSIOLOGY OF PAIN 45

Sensibility to pain in the skin. — It is in the skin that the mechanisms
of sensibihty to pain most easily lend themselves to physiological study
and it is upon work done in this field that most of the facts available are
based.

It will be convenient to enumerate fii'st certain facts which have been
established as the result of work done on the normal and normally inner-
vated skin by a large number of workers, chief amongst whom, by general
consent, is v. Frey.

(1) Sensibility to pain in the skin has, like tactile and thermal sensi-
bility, a punctate distribution. Pain spots react to painful stimuli alone,
just as tactile and thermal spots react to the corresponding stimuli alone,
provided the stimulus in a given case does not pass outside the appropriate
spot.

(2) While the adequate stimulus to a touch spot is mechanical (or
electrical) alone, and the adequate stimulus to a thermal spot (heat or cold)
is thermal alone, the adequate stimulus to a pain spot is mechanical, electrical,
or thermal (heat or cold).

(3) At the same time, however, the mechanical stimulus that would
excite a touch spot has to be increased in intensity in order to stimulate
a pain spot, and the same applies to thermal stimuli. That is to say, the
threshold of the pain spots is relatively high for the same stimuli as
compared with the touch and thermal spots.

(4) The quality of the sensation ' pain ' is characteristically different
from all other sensations in being urgent, in tending to some kind of
compulsory motor reactioA, and in being charged with affective quality.

(5) The cornea possesses sensibility to pain alone, and in it the only
nerve-fibres present terminate in free arborizations among the cells. It is
therefore assumed that the free naked arborization is the end organ of
nerve-fibres giving sensibility to pain.

Thus far then we are able to make the important general statements
that the peripheral pain mechanism is excitable by a number of different
stimuli ichich have tw single physical character in common, that while it
requires a stimulus relatively intense, it yields a reaction relatively excessive,
amd that its characteristic anatomical feature differs strongly from all other
so-called end organs in being a mere free and naked terminal arborization.

It is necessary to give particular attention to the accessibility of the
pain mechanism to a number of different stimuli. Of the other specific
sensory spots in the skin each is accessible to one stimulus alone which
represents a simple unanalysable physical process — the touch spot responds
to movement, the heat spot to transference of heat to the skin, the cold
spot to transference of heat from the skin. The pain spot is accessible to
stimidation by all these, and hence the mechanism is destitute of that
adaptation to registering a single physical change which is characteristic of
all other peripheral mechanisms, including those of the special senses. The
only unitary feature in the stimuli of pain is that they are such that
a moderate increase in their intensity (with the exception of electrical
stimulation) w^ould inflict actual damage. It is suggested in explanation of
this apparent anomaly that in the process of natural selection the skin lias
acquired what Sherrington calls a 'specific sense of its own injuries'. It
must be admitted, however, that there is a difficulty in regarding as the
essence of a stimulus, not the physical characters it actually possesses, but
those it would possess if it were something else. It is also suggested that the

46 REVIEWS

supposed absence of a specific end organ of the pain nerve is in accordance
with its high threshold and its accessibilitj^ to various stimuli, for the
specialized end organ is regarded as at the same time increasing accessibility
to one specific stimulus, and diminishing it to all others.

Supposing these views to be accepted, they still give us no special insight
into the phj^siological meaning of the excessive reaction and unpleasant
affective tone so characteristic of the pain sensation.

When we consider the number of simple sensations which in isolation
are almost altogether free of urgency and aftective tone, the extent to
which these accompany the smallest and most elementary experience of
pain cannot fail to seem remarkable and to be a peculiarity, the explanation
of which should lead us into the inmost significance of the pain mechanism.
Simple touch, heat and cold may at times be accompanied by a certain
amount of affective tone ; for example, some degrees of warmth are exceed-
ingly pleasant, but they have no element whatever of urgency and tend to
produce no impulse towards motor reaction. It seems therefore probable
that the urgency of pain is not an ordinary sensory quality that enables us
to recognize the stimulus, but something superadded and belonging to the
nature of the pain mechanism. The sensation ' touch ' is easily evoked, and
as it were flows quietly and smoothly into the sensorium, its sole effect
being to inform the subject of a simple movement at the periphery ; the
sensation ' pain ' is more difficult to evoke, but when its threshold is reached
seems suddenly to burst upon the sensorium, liberating at the same time
a veritable explosion of reactive energy.

Now it happens that we possess other evidence that the urgent element
in pain is not what we may call a mere ' recognition quality,' is not, that is to
say, merely the means by which we recognize a stimulus likely to become
injurious. In animals and man, after division of the spinal cord, different
reflexes are elicited by stimulation of the lower limb according to the nature
of the stimulus. The response to a stimulus that would cause pain in the
intact animal, is a vigorous widespread and defensive movement ; the
response to a stimulus that would not cause pain in the intact animal is
a totally different movement which will frequently, for example, have
a postural adaptation. Moreover, the response to the ' pain ' stimulus is
prepotent over other responses, and if the two stimuli are applied simul-
taneously or successively, the former will anticipate or interrupt the latter
as the case may be.

The study of pain in the normally innervated skin furnishes us, then,
with a large body of evidence that it is in certain respects unique among all
the other forms of sensibility, and gives us a reason to suppose that the
mechanism which subserves it can be understood only upon principles
perhaps fundamentally different from those in accordance with which the
other peripheral mechanisms manifest their function.

The results of experimental nerve section in man. — In 1905 papers
were published by Dr. Head giving the results of a wholly new method of
investigating the sensibility of the skin — the method, that is to say, of
experimental section of cutaneous nerves in man. In 1909 and 1913
observations founded on the use of the same method were published by
Trotter and Morriston Da vies. More recently (1916) Boring in America
has published a contribution to the same subject also based on the method
of experimental nerve section.

There can be no doubt that the new mode of attack on the problems

THE PHYSIOLOGY OF PAIN 47

of cutaneous sensibility has yielded a body of precisely established facts
which could have been discovered in no other way. The method, however,
is so laborious that in fifteen years it has been used by only three groups of
investigators. It is therefore natural that no exact agreement upon the
whole body of observations has been reached, and that the theoretical con-
clusions arrived at by the different groups of inquiries has been widely
different. The reviewer does not propose to attempt here any critical
examination of these three contributions to the subject, but will merely
try to define what new material has been obtained which bears upon the
physiology of pain.

Numerous as are the differences and discrepancies of detail, there
emerges from the whole series of observations the broad fact tliat during
recovery of a sensory nerve after suture there is a tendency for the
characteristic features of sensibility to pain to be greatly exaggerated, and
for other forms of sensibilit}'' to take on similar characters to a greater or
less extent. The sensation of pain elicited from the recovering area is
extraordinarily intense, explosive, and unpleasant, and causes a practically
uncontrollable impulse to some motor response. The sensation of cold
assumes similar characters to a remarkable extent; it becomes urgent,
explosive, extraordinarily intense, and associated with painful stinging.
The tendency to a motor response is strong, the affective tone unpleasant,
and the sensation distractingly vivid and obsessing.

Traces of a similar kind of intensification are to be met with in
recovering sensibility to heat and to touch, but in neither case are the
phenomena so striking as they are with pain and cold. There are reasons
for supposing that this is due rather to intensification being necessarily less
conspicuous with manifestations of these forms of sensibility than to the
tendency to the production of it being less pronounced. For example, the
intensification of heat very easily produces a sensation of ])ain in which the
thermal element is very difficult to distinguish.

That all sensations in a recovering area tend to undergo what we have
called intensification is, within limits, generally admitted by all workers in
this field. That this intensification represents a modification of all types of
sensibility towards the type which in the normal is shown exclusively by
sensibility to pain is an interpretation shared in neither by Head nor by
Boring, who explain the phenomenon by hypotheses far more elaborate.
Both of these observers proceed upon the assumption that any peculiarities
of sensibility shown in recovering areas must be explicable in terms of
defect only, and are the result merely of some function having not yet
returned. It was pointed out by Trotter and Morriston Davies that the
events which accompany and follow section and suture of a nerve constitute
a pathological process, the existence of which makes it necessary to consider
as a causative factor in the ensuing sensory peculiarities the possibility of
a disturha nee of function as well as a defect of function.

What are the processes which follow upon a nerve section and suture ?
The very familiar histology of these changes need merely be summarized
here in the briefest way.

Beloiv the Section :

(a) Degeneration and disappearance of axis cylinders.

(6) Proliferation of the neurilemma sheath so that its lumen comes
to be occupied by a solid column of cells.

48 REVIEWS

At the Section:

(a) Ramification and outgrowth of axis cylinders from the central
end, some finding their way into the peripheral end; others escaping
into the tissues about the suture line and wandering irregularly
there. There is apparently nothing which attracts the axons to
the peripheral end toward which their course is always irregular
and wandering.

(b) Fibrosis of the tissues in and about the suture line apparently
excited by the presence of the naked axis cylinders, which appear
to be irritants of connective tissue proliferation.

Similar changes are seen after simple division of a nerve, as in an
amputation. The so-called amputation neuroma or bulbous nerve end is
chiefl}'^ made up of very numerous axis cylinders which have issued from
the central end in a veritable spray. These are found pursuing a com-
plicated convoluted course embedded in an extremely dense connective tissue.

The study of such conditions gives one tlie strongest impression that
when a nerve is cut across and left free, there is a pronounced antagonism
between the escaping nerve-fibres and the surrounding connective tissues.
The nervous elements seem to seek to invade, the connective tissue elements
to restrict the invasion, and each seems to be excited to activity by the
other. The changes found about the line of a satisfactory nerve sutui-e are
of the same kind, but naturally of less degree, as many of the outgrowing
axons are received by the waiting and approximated peripheral end. There
is evidence then at least to suggest that the regeneration of a nerve is not
a process that occurs wholly as a matter of course, but rather that it is to
a certain extent resisted and precarious. Moreover, it would appear that
the downgrowing axis cylinders are exposed to irritative influences, and
that those which fail to find the peripheral end of the nerve must be
particularly liable to this. Clinical experience of nerve suture in man
leaves no doubt at any rate of the fact that regeneration is never certain
and frequently incomplete.

We may ask next whether there is any collateral evidence of the
existence of this apparent hostility or incompatibility between the neural
and somatic tissues.

The insulation of the nervous system. — When we consider the anatomy
of the central nervous system we cannot fail to be struck by the number
and complexity of the mechanisms the apparent function of which is to
insulate the nervous tissues from contact with the somatic, except at certain
restricted points where regulated contact is necessary for function.

The dura mater is commonly regarded as functioning chiefly as
a mechanical support. This view scarcely accounts for the dural lining of
the skull and the dural sheaths of nerves, for the extreme density and
imperviousness of its substance and for the fact that of all membranes of
the body it is the one most certainly and rapidly reformed after excision
of part of it. If one excises a part of the dura at an operation, and has to
expose the parts again at a subsequent operation in a few weeks, one
invariably finds the dura completely restored and scarcely distinguishable
from the normal, even though at the first operation one has laid the raw
surface of the scalp flap upon the bare brain. The new dura always
possesses the three characteristic features of the normal membrane — a
glistening inner surface, extreme density of substance and difierentiation
from the overlying parts, so that the scalp readily strips off" it.

THE PHYSIOLOGY OF PAIN 49

Another similar evidence of this neurosoinatic ineonipatiliihty is
afforded by the estabhshed fact tliat it is impossible permanently to drain
the cerebrospinal fluid into any somatic tissue or cavity. The cerebrospinal
fluid apparently shares in the physico-chemical characters of neural tissues,
for wherever it is allowed to escape into the subcutaneous tissues, peritoneal
cavity or so forth, a cyst wall forms aljout it havinf^ all the characters of
a dura. The supply of the central nervous system with vessels, and the
necessary somatic intrusion this involves, is met by every vessel that
penetrates the nervous substance being insulated by the so-called peri-
vascular lymphatic — a structure otherwise very difficult to account for.

Again, it cannot be regarded as physiologically insignificant that
ordinary connective tissue is practically excluded from the structural
support of the central nervous system, while the skeletal properties which
are peculiarly necessary in the brain and spinal cord are supplied by
a special tissue of neural origin, and therefore, unlike all the mesoblastic
tissues of the body inert towards nerve protoplasm.

Pathological illustrations of the same fundamental principle are
numerous and striking. The glioma, although behaving in the brain like
a malignant tumour, never infiltrates the dura or invades the skull — it is
essentially a neural neoplasm. Endothelioma of the dura which infiltrates
the skull and behaves like a malignant tumour there, does not infiltrate the
brain and remains separable therefrom though deeply embedded in it — it is
essentially a somatic neoplasm.

An excellent illustration of the seclusion of the central nervous system
from the body is the impenetrability of the neural tissues to certain drugs —
as is shown, for example, by the resistance of the parenchymatous infection
of general paralysis to antisyphilitic treatment, while the connective tissue
and truly extraneural gumma of the brain responds.

The insulation of the peripheral nerves.— The peripheral nerves from
the very nature of their function cannot be protected from contacts which
would produce reaction by a general seclusion such as is satisfactory in the
case of the central nervous system. Each individual fibre must therefore
be insulated by a special envelope which need not be present around fibres
contained in the spinal cord and brain. The neurilemma seems to fulfil
these requirements. It is absent or rudimentary in the brain and cord,
where the nerve can meet only such tissues as are to it physiologically
inert, but it is present throughout the whole peripheral course of the nerve.
Provided with this sheath a nerve-fibre can traverse any part of the body
and remain inert to all the tissues with which it comes into relation, until
it reaches the structure with which it is functionally related.

Though not strictly relevant, it may be interesting to note that if, as
has already been hinted, the outgrowth of new nerve-fibres during regener-
ation is the result of the stimulating effect of contact with the somatic
tissues, the absence of regeneration in the spinal cord may be due to the
absence of any such excitant contact. Absence of neurilemma and absence
of regeneration within the central nervous system would not then be cause
and effect as sometimes supposed, but both effects of the same thing —
complete physiological seclusion.

When we see neurosomatic contact so carefully guarded against in the
whole structure of the nervous system, we may reasonably suppose that
the contact that is made even in the most careful section and suture of
a nerve, is not without serious eft'ects. That such effects on the side of the

IV. E

50 REVIEWS

nerve are in the nature of a continuous excitation is shown by the results
of the division of nerves in amputation. In every such case the patient's
consciousness of the lost limb is increased rather than diminished by the
operation. He is acutely and more or less painfully aware of this phantom,
and is probably receiving abundant impressions as a result of irritation of
the raw nerve ends by the tissues in contact with them. In the majority
of cases the phantom limb fades within a few weeks and one must assume
that an equilibrium is reached between the invading efforts of the nerve-
fibres and the encapsulating activity of the tissues. In some cases, however,
such equilibrium is greatly delayed or never reached. The ends of the
nerves continue to suffer a persistent excitation, and the patient to be
plagued by a painful phantom limb.

If one is right in supposing such a phenomenon to be due to excitation
of the cut nerve, we may suppose that the sensations experienced would
bear some relation to the number of fibres of various kinds in the nerve.
Now it is probable that sensory fibres reporting movements are those most
numerous in the limb nerves, and corresponding with this is the observed
fact that perhaps the commonest of all complaints by patients is that of
painful cramp-like fixed postures of the phantom limb.

Having reached the position that the fibres of a regenerating nerve are
probably exposed to a varying degree of continuous irritation, we have
next to ask if this can be correlated with that intensification of sensibility
in the recovering area which makes all forms approximate to the type
which is represented in the normal by sensibility to pain.

Now we have seen that pain nerves end in naked arborizations which
necessarily keep them in direct contact with non-neural tissues. May we
not suppose then that the pain nerve is a nerve that is constantly exposed to
a limited mild subliminal excitation and that the secret of the peculiarities
of the pain sensation lies in the fact that the nerve by which it is originated
is a nerve differing from all other nerves in being normally in a state of
continuous excitation. This would at any rate give us a tentative explana-
tion of the explosive quality, the unpleasant affective tone and the tendency
to motor response characteristic of the experience.

The relation of pain to other forms of sensation. — It would follow
from what we have just said that the nerves subserving tactile and thermal,
that is, discriminative sensibility, differ from pain nerves in lacking this
chronic excitation and in being as it were damped down. It will be
remembered that all other end organs than those of pain, widely various in
structure as they are, show one constant feature, and that is that the
terminal nerve fibrils are shut in by a well-marked encapsulating formation.
Whatever may be the function of these organs the constant recurrence in
their structure of this element of encapsulation suggests that the insulation
of the nerve fibril from contact with the surrounding tissues is of great
importance, and the other considerations we have advanced allow us to
suspect the completeness of the insulation of such nerves to be a means of
damping down their general excitability so that the sensations they originate
shall be without urgency and explosiveness and permit of that quite sensory
atmosphere in which alone deliberation and discrimination are possible.

Aspects of nenral evolution. — From this point of view we get perhaps
a glimpse of the way in which the evolution of common sensation has
proceeded.

The germ of a nervous system is a group of cells capable of irritating

THE PHYSIOLOGY OF PAIN 51

and being irritated by the other cells of the body. The essential hostility
of neural and non-neural tissues gives us perhaps a hint of the physiological
significance of the ectodermal origin of the nervous system and of its being
formed at the surface and then sunk en iniibse into the substance of the
embryo. If this hostility is fundamental, not less so is the need for limiting
and regulating the opportunities for contact between the two tissues, which
must therefore be separated b}'' an impenetrable wall in whicli openings are
present only at the exact spots where interaction is valuable. In many
invertebrates the nervous system is a mere diffuse subcutaneous plexus, and
from that state onwards in the animal scale there is an extended series of
increases in the centralization and insulation of the nervous system —
centralization, however it may have come about, very obviously rendering
insulation easier. In discussing the insulation of the human nervous system
we have seen how very elaborate and complete the mechanisms securing
this condition have become.

Now in animals with a diffuse nervous system response to stimulation
seems to be for the most part immediate and urgent. We may suppose
that the relatively uninsulated nervous system yields in general afierent
impulses of the explosive type, and that in such animals what sensation
there is, is all of the quality which survives in us only as pain. Delay
between stimulus and response, which is the fundamental function of
a centralized nervous system, is possible when advancing insulation has
damped down the urgency of incoming sensations ; as soon as delay is
possible deliberation and discrimination appear.

It is at any rate tempting then to regard sensibility to pain as the
survival in us of the primordial mode of sensation. Its urgency and
tendency to evoke immediate motor response is the reproduction of the
normal experience of the lower invertebrate. From it the discriminative
forms of sensibility liave been differentiated by the progressive increase of
insulation. Regeneration of a nerve by exposing a greatly increased
number of nerve-fibres to somatic contact and irritation throws back all
forms of sensibilit}' more or less into the primitive type and provides an
explanation of the characteristically variable phenomena of recovery after
suture. If we view pain as an exaggerated response by a physiologically
irritated nerve, it is possible to get some conception why pain is the
commonest of symptoms and w^hy it is so apt to become inveterate. Pain
is, as it were, physiologically only just not present in us all, and what
appears to be a very slight disturbance pathologically may prove an eflfective
and incurable excitant of it.

Boring, E. G. Cutaneous sensation after nerve division. Quart. J. Exx)er.
Fhysiol, 1916, 10, 1.

Head, E., Rivers, W. H. R., and Sherren, J. The afferent nervous system
from a new aspect. Brain, 1905, 28, 99.

Trotter, W., and Morriston Davies, H. (1) Experimental studies on the
innervation of the skin. J. PhtjsioL, 1909, 38, 134.

Trotter, W., and Morriston Davies, H. (2). The peculiarities of sensibility
found in cutaneous areas supplied by regenerating nerves. J. f. Psyclwl. u.
Neurol {Ergiinzungsheft), 1913, 20, 102.

W. T.

E 2

ABSTEACTS

SURGERY

ExtOGius, A. Studiei- och betraktelser ofver den Dupuytren'ska finger-
kontrakturens patogenes. [Studies in the genesis of Dupuytren's con-
traction.] Finsla LiikrsallsJi. Handl, 1920, 62, 489-506.

Of the 22 cases of Dupuytren's contraction treated in the period 1888-
1920 at Kirurgiska Sjukhuset in Helsingfors, 18 were males, and only 4
females. In 2 cases the age of the patient was between 10 and 19, in 6
between 20 and 29, in 4 between 30 and 39, in 4 between 40 and 49, and in
6 between 50 and 59. Thus, in more than half the total the diseatje began
before the 40th year. The disease was bilateral in no fewer than 12 cases;
in 7 it was confined to the right and in 3 to the left hand. In 4 cases there
was a family history of the disease, and in one of these it had appeared in
as many as 16 members of the same family distributed over 4 generations.
No correlation between manual labour and the disease could be uniformly
established, and several of the patients belonged to the intellectual classes.
Among the 50 professors of Helsingfors, 5 exhibited this deformity.

Krogius examined microscopically 13 cases, in 2 of which the contraction
had lasted only a few months. In others it had lasted for several years, in
2 for more than 20 years. He also examined microscopically the palmar
aponeurosis of new-bom infants, and found among the bundles of connective
tissue small islands of transversely striated muscle obviously undergoing con-
version into connective tissue. Among his sections of Dupuytren's contrac-
tions he could never find in the thickened palmar aponeurosis any small-celled
infiltration or other sign of an inflammatory reaction. Nor could he ever
in these cases encounter transversely striated muscle-fibres. He concludes that
this condition is a developmental disorder of the superficial palmar muscle
(flexores breves manus superficiales). Just as the palmar aponeurosis itself
must be regarded as a fibrous equivalent of certain muscles of the palm in
some mammals and in the human embryo, so the fibrous tissue of Dupuytren's
disease may be regarded as a product of an embryonic relic of the same
muscular layer. The subjects of this disease do not possess atavistic muscles
in the strictest sense of the word, but they develop the disease because,
imbedded in the palmar aponeurosis, there are musculo-tendinous islands
which later in life develop into fibrous tissue and thus provoke the charac-
teristic contraction. But though Krogius regards the disease primarily as
one of ' embryonic tendency ', he does not deny the importance of trauma in
a certain proportion of cases ; it may, indeed, be the determining and
exciting cause. C. L.

NEUROLOGY 53

NEUROLOGY

HussT, A. F. The psychology of the special senses and their functional
disorders. Oxford Medical Publications, 1920.

Under the above title Dr. Hurst has published in full the Croonian
Lectures delivered by him in 1920. The book is a record of the extensive
observations by him and his colleagues on the action of suggestion in
producing functional symptoms in normal people, and in relieving gross
manifestations in hysterics. The author has shown in a very conclusive
way that many physical signs usually considered to be pathognomonic
of organic disease are in reality functional ; and great praise is due for the
thorough manner in which he has worked at this subject over a wide field.
In view of the publicity which his work enjoys, it will be difficult for
a practitioner to fold his hands over any kind of case and say that nothing
can be done ; for Dr. Hurst has shown that in every case of organic disease
there is an hysterical element, and it should be the business of the doctor
to disentangle this and get rid of it. This is all to the good, and may,
perhaps, be a corrective to another school of thought, now enjoying an equal
publicity, whose avowed aim is to register the symptoms of illness for years,
it may be, before there is any disability at all.

Dr. Hurst's work is so good that one wishes that his vision were
a little wider, that he could see that his dictum, ' Hysteria is a condition in
which symptoms are present which have resulted from suggestion and are
curable by psychotherapy,' does not cover the whole ground, and that his
associated statement, that after the removal of such symptoms by psycho-
therapy the patients were fit and no more liable to develop new symptoms
than other people, is not wholly in accordance with fact. Not only did
those who worked in other hospitals see Dr. Hurst's failures from time to
time, just as he tells us he saw theirs, but in this very book there are
cases recorded which demonstrate that these two propositions of his are
untenable.

He describes two examples of hysterical deafness, in each of which the
cure of the deafness was followed by amnesia, which had not been present
before. He mentions these two striking occurrences without comment, and
it is clear that for him they were of little significance. One man had a com-
plete loss of the whole epoch, some sixteen months in duration, between his
enlistment and the day on which his deafness was removed. So complete
was it that he had to relearn the whole of his drill when he was returned to
duty. Now, are we to suppose that this amnesia was not of hysterical
nature "? If it was, who or what had suggested it ? It was so dramatic that
it is astonishing that so important a question, involving as it did the impli-
cation of faulty technique, was overlooked. Why was it not cured by
psychotherapy before the poor wretch was sent back ? An amnesia of
sixteen immediately preceding months would be no light handicap for
any one of us with which to face the world. Dr. Hurst must have con-
sidered it hysterical; he would not have sent a man back to duty with
a brain lesion so gross as to have caused a symptom like this. Is it not
possible that beneath the manifest symptom of deafness there was a strong,
perhaps unconscious, wish to have nothing more to do with war, that when

54 ABSTRACTS

Dr. Hurst made a return to war likely the mind reacted by dissociating all
knowledge of anything that had to do with war, and that in this way the
wish was fulfilled ? Surely there is here an instance of a mental attitude in
these patients, which it might be advisable to understand and to alter,
something quite different from a sj'mptom, but which was the cause of
a symptom that did not arise from suggestion, was not curable by the
psj^chotherapy of persuasion, but yet was an hysterical symptom.

Dr. Hurst has devoted considerable energy to the study of the
so-called stigmata of hysteria; and because he has found that they,
both somatic and mental, are always artifacts, he has somehow come to
the conclusion that there is nothing in hysteria beyond the symptoms.
It is a strange conclusion from such a premiss ; for the stigmata, if they
existed, could themselves be only symptoms, symptoms of a more permanent
character than paralyses or contractures. Their disappearance from the
scene leaves the problem untouched. Hysterical symptoms characterized
by loss are explained by the psychological mechanism of inattention.
Physically, this is described as being probably due to retraction of den-
drites. In severe cases these remain retracted during sleep, so that the
hysterically deaf do not hear even in sleep. Dr. Hurst says that he
hoped to be able to cure hysterical deafness by hypnosis, and was sur-
prised that he failed ; but he found an explanation in the probability that
the dendrites were retracted in hypnosis just as in sleep. This is very
interesting, for it is a good example of the way in which a fanciful pathology
leads astray. It is possible that, though Dr. Hurst consciouslj^ expected cure
by hypnosis, his unconscious knew from the sleep analogy that he would
fail, and that he therefore tried only half-heartedly and did fail. The
present writer had no difficulty in curing several cases of hysterical deafness
by hypnosis.

In the section of the book dealing with ocular troubles there is curiously
no mention of what used to be called neurasthenic asthenopia, where the
patient can read quite well for five or ten minutes and then everything gets
blurred. This is probably the commonest of all functional eye troubles,
much commoner than blindness or fixed accommodation difficulties. As the
patient can always see clearly for some minutes, it is difficult to fit the
symptom into a pathology of ' not looking '.

It must be said again that Dr. Hurst's work is of great value. The
removal of hysterical symptoms is well worth while. If the patient has not
to return to a difficult environment nothing more may be needed. Even if
he has, it is a useful preliminary to further investigation; it makes the
patient willing to co-operate. T. A. R.

ViETS, H. Belatiou of the form of the knee-jerk and patellar clonus to
muscle tonus. Brain, 1920, 43, 269.

Viets, working in Sherrington's laboratory, has investigated the relation
of muscle tone to the knee-jerk. This subject was recently reviewed in
Medical Science, and there is little to add to what was then stated (1920,
2, 346).

He finds that in the spinal animal the knee-jerk is a single twitch
followed by rapid and complete relaxation of the muscles. There may be
a single rebound jerk, or several, after relaxation.

In the decerebrate animal, or in the spinal animal, when the vasticrureus

NEUROLOGY 55

is rendered tonic by reflex stimulation, the knee-jerk is a single twitch
followed by a continued contraction, the muscle assuming a new and shorter
length after the jerk. There are then two elements in this jerk, the twitch
or ' contractile ' element, and the tonic or ' plastic ' element. It is this
second element that is the true index of muscle tone. It varies according to
the tone of the muscle and disappears when this is reflexly inhibited.

The flaccid muscle of the spinal animal is not completely toneless, but
contains an element of spinal tone, which can be reflexly inhibited. When
this inhibition is complete the muscle gives no jerk.

Clonus is best o])tained with a low degree of tonus, and the range
of tonus through which it is obtainable is small. Beyond this range, either
increase or decrease of tonus causes it to disappear. The appropriate degree
of tonic shortening is called the ' neutral tension ' of the muscle. A true
clonus consists of a series of self-sustained twitches, regular in rate and
amplitude, superimposed upon a tonic shortening. Its rate ranges from 12
to 17 per second.

It is perhaps unfortunate that the slighter degree of clonus which dies
out after five or six Ijeats is called ' pseudo-clonus ' by Viets. There seems
no fundamental difierence between it and the stronger clonus that persists,
while the specific meaning attached to the phrase by the clinician makes this
use of the word misleading.

The plastic element of spasticity in man is possibly better appreciated
than Viets imagines, and its occurrence has been observed and recorded.
However, owing to practical difficulties in graphic registration of reflex
movements in patients, to which Viets refers, there have been no adequate
permanent records made.

The tendon-jerks, obtainable in man from flexor muscles, have never
been examined in experimental animals. In view of the more or less selec-
tive incidence of tonus, it would have been interesting had some reflex
comparable with the hamstring-jerk of man been investigated in the
decerebrate and spinal animals, and its dependence upon contractile tone
determined. F. M. R. W.

WIX.S017, S. A. K. On decerebrate rigidity in man and the occurrence of
tonic fits. Brai7i, 1920, 43, 220.

Wilson describes a series of cases in which, in association with various
abnormal conditions of the brain, and with or without loss of consciousness,
there was observed a persistent tonic extensor rigidity of the musculature.
This may be unvarying in intensity, or it may be periodically increased by the
occurrence of ' tonic ' or postural fits. These are the ' tetanus-like seizures '
of Jackson, and they may also occur apart from persistent rigidity. Wilson
regards this rigidity as strictly analogous with the decerebrate rigidity of
Sherrington, while the tonic iits are in reality ' attacks of decerebration '.
When the condition occurs during conscious life, it is not associated with
tonic fits, and it may be localized in one or more limbs or segments of
a limb. Underlying the involuntary movements of chorea and athetosis
is a ' postural background which is composed of part of the complete decere-
brate attitude '.

The essential feature of the lesions producing these phenomena is that
they dissociate the cortex from the mesencephalo-cerebellar level, and at the
same time leavie the latter functionally intact.

56 ABSTRACTS

The rigidity is the expression of a non-cortical motor mechanism which
finds its full expression in decerebrate rigidity and in complete tonic
fits.

The rigidity produces extension of the head, neck, and trunk, sometimes
with opisthotonos, the upper limbs are fully extended and adducted with the
forearms pronated and the wrists and fingers flexed. The legs are extended
and adducted, the feet plantarflexed, and the toes dorsiflexed. If the two
halves of the body are unequally affected the head is rotated to one side. The
tonic fits are sudden in onset and cause a marked increase in the rigidity, but
do not modify its form. They are associated with slowing of respiration,
sometimes with Cheyne-Stokes rhythm, and dilatation of the pupils. He
has observed cases in which tonic fits occurred, but in which there was
no residual rigidity between the fits.

Several of the cases did not die, and therefore the site and nature
of the lesion could not be accurately determined, but in such cases as came
to autopsy the lesions were various — cerebral haemorrhage, meningeal
inflammation, and tumours — while he also cites hysteria as a cause. In
cases of athetosis and of chorea, Wilson, also on purely clinical grounds,
believed that he detected partial or localized manifestations of decerebrate
rigidity.

Wilson makes no reference to previous work devoted to the study
of decerebrate rigidity in man, and therefore does not include the rigidity of
hemiplegia and of spastic paraplegia, in which this tonic manifestation has
been most definitely identified. In fact, he says, in reference to hemi-
plegia, ' It might be supposed, simply, that the ordinary hemiplegic attitude
of arm and leg is a unilateral decerebrate posture, but this is the case only
in a sense.' What this sense may be he does not add, nor is any explana-
tion afforded of the spasticity of pyramidal tract lesions, though this might
be considered to demand consideration in this connexion.

It is not certain from the clinical records that in all the cases there
is evidence of the withdrawal of cortical control, which is an essential
condition for the appearance of rigidity. This may be reasonably objected
to the cases of chorea, while it is not very clear why pronation of the hand
without any trace of underlying rigidity should be regarded as a segmental
decerebrate rigidity.

It seems unfortunate, too, to complicate a fairly clear conception by the
admission of the attitudes of hysterical fits. Surely these cannot be attri-
buted wholly to a ' release mechanism ', but demand something more than
an uncontrolled normal activity of the midbrain postural centres for their
explanation. This is also true of 'tonic fits'. Quite possibly they may
arise in the same centres as decerebrate rigidity (though Jackson did not
assert this), but while simple rigidity may be regarded as ' release pheno-
menon ', a tonic fit has all the appearances of an active and explosive
discharge of energy, as an irritative phenomenon, in other words. These
have always been carefully distinguished from simple release phenomena.
That Wilson fails to draw this distinction is seen from his reference to
Graham Brown's stimulation experiments on the red nucleus, as well as
from his view that tonic fits are merely attacks of decerebrate rigidity.

In short, Wilson appears to include phenomena which have little or
nothing in common, under the term decerebrate rigidity ; he makes no
reference to the most commonly seen forms of this condition; while the
conditions of disease underlying the tonic states and involuntary movements

NEUROLOGY 57

comprehended within his definition include irritative lesions, ditluse and
focal paralytic lesions, and, finally, hysteria.

At the same time, the rigidity and the tonic fits described are interest-
inf and obscure phenomena, the elucidation of which is a prol)]em of great
physiological importance, and it is a distinct advantage that they should be
considered as possible expressions of the tonic rigidity so fully described by
Sherrincrton. This, however, has certain characteristics of incidence and
(quality, notably its plasticity and the reflex reactions that accompany it, and
we should need a more minute description of these features in clinical cases
than Wilson -provides, before the identification could be attempted with any
degree of accuracy. F. M. R. W.

BOGEB, H. Reveil liivernal de I'epidemie encephalitique et revivescence saison-
niere des encephalites ii forme prolongee. [The winter incidence of epidemic
encephalitis and the seasonal recurrence of chronic forms.] Bull et mem.
Soc. med. d. hop. de Par., 1921, 36, 1633.

Roger draws attention to the almost exclusive incidence of lethargic
encephalitis during the period November-March, in every country in which
it has appeared, and for every year since 1916.

In addition, he records several personally observed cases, in which the
onset of the disease during the winter 1919-120 was followed by the persis-
tence of such symptoms as muscular (myoclonic) twitching, or the paralysis
agitans syndrome. With the arrival of December 1920 these cases have
shown a marked aggravation of their symptoms and the appearance of fresh
manifestations of the disease.

One of these cases, as briefly recorded by Roger, provides an interesting
case for commentary. During the winter 1918-19, the patient, a man, had
a short illness ushered in by two days' fever and consisting of asthenia and
diplopia lasting for two weeks. Recovery ensued, and the patient appears
to have been in normal health until two months ago, when transient
diplopia was noted. More recently a sudden apoplectiform attack ushered
in an illness consisting in right hemiparesis, ocular palsies (not specified), and
lethargy.

Doubtless, the diagnosis of encephalitis is justified in this case, but
from the brief account given one is tempted to ask why not disseminated
sclerosis or cerebral syphilis ? F. M. R. W.

PATHOLOGY AND BACTERIOLOGY

TwoKT, F. W. Researches on dysentery. Brit. J. Exper. Path., 1920, 1, 237.

Three tjrpes of special forms can be isolated from dysentery and allied
bacilli. Type A shows moderately thick but long bacilli, which may twist
like a spirochaete. Type B shows long thick rods, some swollen in the
middle or at one end, and these may break open and set free granules. The
bacilli are associated with round forms and many free gi-anules. Type C
bacilli are like Type B, but shorter. There are many granules and round
forms, also thick branching units. In older cultures most of the units are

58 ABSTRACTS

globular, and the protoplasm may collect as a semi-lunar mass round the
circumference. A filter-passing dissolving material may be present in
cultures of dj^sentery bacilli, &c., which breaks down the bacilli into granules.
The special types A, B, and C are produced by normal bacilli, but some
smaller units are always present. The special forms are probably not stages
in a true life-cycle, as the normal type is not produced in rotation, and it is
doubtful if they are mutations. Special types may be produced for
performing special work, and types in ' pure culture ' may be likened to bees
in a swarm. They are possibly of importance in connexion with incubation
period, successful infection, and production of immunity. Sexual multi-
plication is not proved, but may exist in normal cultures. P. F.

TocuNAGA, H. Ueber die Biologie der Influenzabazillen. [The biology of
the influenza bacillus.] Deutsche mcd. Wclmschr., 1920, 46, 1857.

An investigation into the effect of haemoglobin upon the growth of
B. influenzae. PfeifTer and all workers up to now have looked upon the
iron-containing pigment fraction of haemoglobin as the essential body for
growth, but the present author concludes that it is not this pigment but the
globin fraction which is necessary. He arrives at this by showing that the
haematin fraction will not allow growth, a fact which has been known
always, while globin prepared by him from haemoglobin permitted good
growth. Although the method of preparation ascribed would not be
expected to produce pigment-free globin (Reviewer), nevertheless his
specimens ' on analysis showed no iron reaction '. Method not stated.

P. F.

Mackie, T. J., and IIowi.and, C. C. The value of simultaneous testing for
the Wassermann reaction with two different antigens and the ' ice-box
method'. Brit. J. Exper. Path., 1920, 1, 219.

(1) The sensitiveness of the Wassermann reaction as here described can
be increased, especially in early primary and treated cases, by testing
simultaneously with a liver lecithin plus cholesterol antigen and a heart
extract plus cholesterol antigen, i. e. a proportion of weakly positive reactions
can be detected in this way which would escape notice if only one of these
antigens were used. (2) The ice-box modification as applied to the method
described does not confer any appreciable advantage over the usual procedure
of incubating the mixture of antigen, serum, and complement at 37° C. for
14 hours. P. F.

Fbuhwald, II . Ueber Spirochatenbefunde in Lymphdriisen. [Spirochaetes
in lymphatic glands.] Wien. Min. Wchnschr., 1920, 33, 999.

An estimate of the value of examining for spirochaetes in fluid removed
by puncture of the regional glands, in the diagnosis of syphilis. This
procedure is recommended in cases of primary syphilis in which the chancre
is healing or has been treated with antiseptics. The syringe needle is
pushed into various parts of the gland and a few drops of saline are injected.
Aspiration is then started while the gland is being massaged.

In 24 cases of primary syphilis, S. pallidiiini was found in the inguinal
glands 20 times, 7 times in 18 cases of acute secondary s}^hilis, and 7 times
in 27 of later secondary syphilis.

PATHOLOGY AND BACTERIOLOGY 59

Thus, in the hands of the author, the method is of very considerable
value for the diagnosis of primary syphilis.

Attempts were then made to disclose spirochaetes in ' rests ' in the
glands of later cases of syphilis. Four tertiary glands were examined, but
none were found.

Spirochaetes were, however, found in enlarged glands of two cases
described as ' latent ' (i. e. persons with no obviously conspicuous signs of
syphilis at the moment, but not closely examined. — Reviewer). One had
a positive W.R. and had syphilis 2 1 years before ; the other was a recent
ease of secondary syphilis, in whom the obvious signs had receded after
a dose of salvarsan, P. F.

Habebmann, R., u. MaueIiSKAOEn, F. Die Bedeutung der Hoflfmannschen
Driisenpunktion fiir die Fridierkennung der Syphilis. [The value of glaud
puncture in the early diagnosis of syphilis. ] Deutsche med. Wchnschr., 1920,
46, 574.

Thirty-three cases of primary syphilis were examined by gland puncture
and in 30 >S. pallidum was found. In 1 1 of the cases the method permitted
an early diagnosis, which, otherwise, was impossible.

In the secondary period spirochaetes were not found so often. P. F.

Dbeyfus, G. L. Die Beschaffenheit des Liquor cerebrospinalis — das entschei-
dende Moment fur Prognose und Therapie in den einzelnen Stadien der Syphilis
des Nervensystems. [The constitution of the cerebrospinal fltiid — the
deciding factor for prognosis and therapy in syphilis of the nervous system.]
Miinchen. med. Wchnschr., 1920, 67, 1369.

A summary of the author's long-continued investigations into tlie
relation of the state of the cerebrospinal fluid to the prognosis and treatment
of cerebrospinal syphilis.

A pathological cerebrospinal fluid in the early stages of syphilis
may revert to the normal without treatment ; from the latent stages
onwards, however, such a fluid is an index of grave progressive processes in
the C.N.S. This is particularly so when the W.R. is positive in high
dilutions. The author has observed in many cases a progression from
cerebrospinal (interstitial) to generalized encephalitis (G.P.I.).

Eighty per cent, of 72 cases of early syphilis without obvious nervous
signs show pathological cerebrospinal fluids (including slight increase of
pressure as such). Most of these become normal on treatment, but some
become abnormal again, and therefore it is essential in every case of syphilis
to repeat lumbar puncture about 12 months after the end of treatment.
The first course of treatment is vastly more important than subsequent
courses for preventing relapse.

Among 260 ' latent ' syphilitics, without nervous signs, at all periods of
infection 17 per cent, had abnormal cerebrospinal fluids.

Cases of cerebrospinal syphilis (371 cases) require intensive treatment
in proportion to the degree of abnormality. Many cases can thus be brought
to normal, but others not.

In tabes (327 cases) a normal cerebrospinal fluid may be found, but this
does not necessarily indicate a cure of the process, and treatment should
nevertheless be carried out.

60 ABSTRACTS

The short summary of the author's work indicates again that no case of
syphilis can be properly controlled or treated without the information
supplied by repeated lumbar puncture. P. F.

Bruusgaabd, E. Neurosyphilis. [Neurosyphilis.] Norsk Mag. f. Lcege-
vidensh, 1920, 81, 76-84.

Professor Bruusgaard's main theses may be classified thus. (1) It is
certain that an inadequate, unsystematic course of salvarsan treatment may
be harmful, as it often gives an atypical turn to the disease, notably neuro-
recurrence. (2) In the case of primary syphilis with a positive Wassermann,
specific treatment must be pushed vigorously, and prolonged observation is
required before the success of abortive treatment can be claimed. (3) In
cases of primary syphilis with a negative Wassermann, modern specific
treatment can almost invariably abort the disease and effect a complete cure.
(4) If early cases of neuro-recurrence are traceable to inadequate specific
treatment, then energetic, systematic treatment should banish this com-
plication.

In support of hypotheses (1) and (4), B. gives the following statistics
from the dermatological department of the Rigshospital in Christiania.
Since 1912, 630 cases of recent secondary syphilis were observed, and
among them were 10 cases of neuro-recurrence. After giving details of
each of these cases, B. remarks that common to all was the inadequacy of the
specific treatment. In some cases only a few injections of salvarsan or neo-
salvarsan had been given at long intervals. In others numerous injections
had been given, but the each injection had been small. At this point
B. digresses with the reminiscence that his predecessor, Caesar Boeck,
objected to the use of mercury in early syphilis because its course was only
modified, and not always to the benefit of the patient. As for B.'s fourth
hypothesis, he finds it supported by the fact that since he adopted, in 1915,
energetic, systematic treatment of early syphilis, he has only once seen
a case of neuro-recurrence among 420 cases of early secondary syphilis.
His treatment for men and women was different. The former were given
salvarsan combined with injections of salicylate of mercury, the latter neo-
salvarsan combined with mercurial inunctions. The fu-st course of treatment
was the most energetic on the assumption that it might also be the last.
Treatment was continued long after the disappearance of clinical symptoms
and the development of a negative Wassermann. The total amount of
salvarsan given in one course was often 5 to 6 grm., and of mercury up to
2 grm. For women the total was 6 to 10 grm. of neo-salvarsan, and often
as much as 250 to 300 grm. of mercurial ointment. B. pushes the mercurial
treatment of women more than that of men because the action of neo-
salvarsan is far less efiective than that of salvarsan. Referring to the one
case of neuro-recurrence in this series, B. confesses that, had he but taken
the precaution of examining the cerebrospinal fluid before the patient's
discharge, this disaster might have been avoided. C. L.

Hoi.i.AirD. Neurosyphilis. [Neurosjrphilis.] Norsk Mag. f. Lcegevidensk.,
1920, 81, 84-7.

Discussing the prognostic significance of changes in the cerebrospinal
fluid in syphilis, Holland regards globulin and an increased number of cells
as of doubtful significance, for these two factors have not been adequately

PATHOLOGY AND BACTERIOLOGY 61

checked by control examinations in other diseases and in healthy persons.
He attaches more importance to Wassermann's reaction. Lumbar puncture
in 92 cases of recent syphilis was undertaken, the material, after the
exclusion of 6 cases of congenital syphilis, being grouped in two classes.
The first included 44 consecutive cases before the institution of treatment.
In one case all three tests (globulin, cells, Wassermann) were positive, the
patient being a man of 45, with headache as the only clinical symptom. In
three other cases, one of the tests was positive, and in one case two of the tests
(globulin and cells) were positive. The second series of cases included 42
patients on whom lumbar puncture was performed because clinical evidence.,
such as headache, suggested morbid changes in the cerebrospinal fluid.
While only 5 of the patients in the first group showed morbid changes, 17,
or 42 per cent., showed morbid changes in the second group. Holland gives
these findings with reserve, admitting that they may prove instructive only
in conjunction with similar investigations by other workers. C. L.

ScHon, H. J. Nervelidelser ved tidlig Syfilis og deres Behandling. [Nerve
lesions in early syphilis and their treatment.] Hosp.-Tid., 1920, 63, 57-9.

In a preliminary report to the Danish Dermatological Society, Schou
reviews his findings in about 800 cases of syphilis of less than 3 years'
standing. About 1,200 examinations of the cerebrospinal fluid was made,
the number of cells, the amount of the proteins, and Wassermann's reaction
being investigated. The cases were classified according as they had been
treated or not, and according to the stages of the disease. There were 491
cases of recent syphilis in which absolutely no treatment had been given.
Among them were 56 cases of primary syphilis with a positive Wassermann
(blood), and in 12 per cent, morbid changes were found in the cerebrospinal
fluid. The same percentage was found in 75 cases of primary syphilis in
which Wassermann's reaction (blood) was negative. This percentage rose to
23 in 300 cases of secondary syphilis, and to 39 in 41 cases of syphilis of
6 to 12 months' standing. The cerebrospinal fluid showed morbid changes
in 27 per cent, of the 15 cases of 1 to 2 years' standing. Schou notes as
remarkable that most of the changes observed in the cerebrospinal fluid
coincided with the second half-year of the disease. The changes found in
the cerebrospinal fluid were, in the order of their frequency, pleocytosis,
globulinosis (25 per cent.), a positive Wassermann (21 per cent.), and
albuminosis (14 per cent.).

Altogether, 133 patients with primary and secondary syphilis were
examined by a neurologist who found partial or complete loss of the abdominal
reflexes in 9 per cent,, exaggeration of the patellar reflexes in 20 per cent.,
and sensory disturbances of the trunk and lower limbs (of a uniform,
radicular type) in from 5 to 10 per cent. Among patients with the triad :
absence of patellar reflexes, lively tendon reflexes, and slight sensory
disturbances, the cerebrospinal fluid showed morbid changes in 60 to 90 per
cent., i. e. they were 3 to 4 times as common as in syphilitics not showing
this triad. There would, therefore, seem to be some connexion between
spinal meningitis and nerve symptoms. In about one-third of the cases of
primary and secondary syphilis headache was present and was almost
invariably associated with an increased intraspinal pressure. Optic neuritis
was found in 3 per cent, of 443 cases of recent syphilis, and disturbances of
the auditory mechanism in about 14 per cent, of 135 cases. Curiously

63 ABSTRACTS

enough, the cerebrospinal fluid seldom showed morbid changes in these
cases — a fact suggesting that there is no connexion between lesions of the
eye and ear and spinal meningitis.

To investigate the course of early syphilitic meningitis, Schou repeated
lumbar puncture at intervals of a half to two months and found that, in 53
patients in the second stage, cerebrospinal fluid which originally showed
morbid changes invariably showed diminution of these changes or their
complete disappearance after treatment. But when it was normal to begin
with, it subsequently showed morbid changes in a certain number of cases
in spite of, or possibly because of, treatment. In 9 cases of primary disease
examined again after an interval of a half to two months, the second lumbar
puncture showed that a negative finding on the first occasion is very often
followed by a positive finding on the second, although in the interval specific
treatment has been vigorously pushed. In other words, certain changes in
the cerebrospinal fluid tend, like Wassermann's reaction in the blood, to
develop in spite of treatment. At one time the effect of this tendency was
labelled ' neuro-recurrence ', but it really is the expression of the further
development of a slight attack of syphilitic meningitis. In 39 cases, 3
' re-punctures ' were made about a year after infection, and they showed
that, whether the cerebrospinal fluid be ' positive ' or ' negative ' in the
secondary stage, it will as a rule be ' negative ' after a year. But, in a few
cases, it will still be markedly ' positive ', although, as a rule, the patient
notices no effects thereof. Four ' re-punctures ' in 20 cases in which the
disease had lasted 2 to 5 years showed the same phenomenon ; in a certain
proportion of cases latent syphilitic meningitis persists.

Discussing the proposition that these cases, in which the cerebrospinal
fluid is abnormal, subsequently terminate in general paralysis and other
nervous diseases of syphilitic origin, Schou remarks that this can hardly
happen to all, for on clinical evidence only 10 to 15 per cent, of all cases of
syphilis develop these late syphilitic lesions. The cases he suspects as being
most liable to develop general paralysis, &g., are those in whicli the cerebro-
spinal fluid shows morbid changes directly after infection. There were 12
such cases among 500, i. e. 2-5 per cent. A second class of case which would
probably be peculiarly liable to genera^l paralysis, &c., would include those
in which morbid changes in the cerebrospinal fluid persisted or relapsed.
There were 6 such cases out of 60, i. e. 10 per cent. Adding this percentage
to the 2-5 per cent, already referred to, he gets a ratio of 12-5 per cent.
This, he points out, tallies with the ratio suggested by clinical evidence.
He admits, however, that this selection of candidates for general paralysis,
&c., is based on purely hypothetical grounds, and only systematic neurological
examinations of many syphilitics conducted over a considerable period can
control his hypotheses. C. L.

BORDET, J., et CiucA, M. Exsudats leucocytaires et autolyse niicrobienne
transmissible. [Leucocytic exudates and a ti*ansmissible bacterial auto-
lysin.] Compt. rend. Soc. de hiol, 1920, 83, 1293.

BORSIIT, J., et CzuCA, M. Le bacteriophage de d'Herelle, sa production et son
interpretation. [The production and interpretation of d'Herelle's bacterio-
phage,] Compt. rend. Soc. de hiol., 1920, 83, 1296.

How are variations carried on to descendants to reproduce the characters
of species 1 There must be a factor, induced by some external influence.

PATHOLOGY AND BACTERIOLOGY 63

which acts directly on a cell to cause a variation. When this factor is
produced by the cell itself and operates continuously, it is easy to under-
stand how a variation is established, so lonsi; as the causative external
influence continues. When, however, this external influence only operates
for a short time and then ceases after having excited the intracellular
factor, we must assume that this factor is capable of regular rejuvenation
from generation to generation in order not to lose its original energy. If
the factor of variation could not propagate itself the variation would cease.
In practice it must be presumed that the factor, in order to carry on its
effect upon the cell, must be renewable by the variation it induces.

Suppose, ' now, that the cell is a microbe and that the intracellular
factor inducing variation is an active substance produced by the microbe as
a result of the fleeting stinmlus of an external influence. We must deduce
that the microbe must transmit the aptitude to form this substance to its
descendants. If we further imagine that this substance is diffusible in
a culture medium, the mere contact of a medium in which such a microbe
has grown will confer the same variation upon allied microbes placed in the
medium, and these in their turn to others, and so on ad infinitum. If the
variation relates to the life or death of the microbe, it will be seen that the
species may propagate indefinitely an aptitude, for instance, for autolysis.

If a guinea-pig is inoculated intraperitoneally with several doses of
B. coli, the peritoneal fluid, when added to a normal culture of the same
species, will confer upon it the power of autolysis, which is transmissible
from culture to culture. The microbe in such a clarified culture may be
killed by heat, but still the power of transmission of autolysis remains.
The technique is as follows : the exudate from the guinea-pig is placed in
a tube of broth and the few surviving microbes grow therein. The culture
is now heated to 58° C. for 30 minutes and then diluted with several
volumes of broth, reinoculated with B. coli and incubated for 24 hours at
37" C. and 2 or 3 days at room temperature. The culture tends to become
clearer rather than more opaque. If this is now sterilized by heat, it is
found either to prevent growth of B. coli or to lyse it if it has already
occurred. Thus the species has developed the hereditary power of autolysis.

When a culture has been lysed a few bacteria still remain alive and
when subcultured on to broth these grow very feebly, but when on to agar
they may be trained to grow well. Such an agar culture has altered
characters and does not lose its transmissible lytic power. It is more
pathogenic for the guinea-pig than the original strain and is less readily
phagocytosed. Further, 1 c.c. of an autolysed and sterilized culture injected
into the peritoneal cavity of a guinea-pig will protect it from a dose of
B. coli which kills a control in 8 hours.

In the second paper the authors point out that these phenomena explain
the lytic action described by d'Herelle (and previously by Twort. — Reviewer)
and ascribed by him to a living filter-passing virus which preyed on the
microbes in a culture (vide Medical Science, 1920, 2, 182j. P. F.

Thomsen, O., and WuLPr, F. Experimental studies of the mode of action
of antimeningococcal serum. Acta nied. Scandhuivica, 1920, 54, 65.

The sera used by the authors were monovalent, prepared by injecting
horses and rabbits with meningococci derived from Danish cases. 94 per
cent, of these cases were of one serological type and dift'ered from any of

64 ABSTRACTS

those described by Gordon in this country. The serum had a marked
protective effect for mice and guinea-pigs if injected with or before the
bacteria.

In order to arrive at an estimate of the therapeutic value of a sample
of serum, it is necessary to know which immune factor is responsible for
cure. Kraus and recently, in this country, Gordon have favoured the endo-
toxic factor, but the authors do not agree that an endotoxin is in question.
They hold that meningococci do not multiply within the bodies of laboratory
animals and that death occurs according to the volume of injected cocci as
a consequence of poisoning by bacterial proteins.

When living meningococci are injected into the peritoneum of mice or
guinea-pigs, they rapidly pass from the cavity into the blood-stream, and
after 3 or 4 hours none are left. When the injection is intravenous the
number in the blood-stream is rapidly reduced and they are found in the
spleen, liver, and bone-marrow undergoing phagocytosis or autolysis, which
latter leads to the poisoning of the animal. If, on the other hand, meningo-
cocci are injected into the peritoneum with serum, very few pass into the
blood and these only just after injection. The animal is not poisoned.
Similarly after intravenous injection the blood is found to be sterile after
a few minutes.

To account for these phenomena, the authors were unable to find
evidence of bacteriolysis. The reduced number of colonies on plating was
due to agglutination and not to death of the cocci. Actually a marked
agglutination occurs in the peritoneum, and this prevents the absorption of
the cocci into the blood. After a short time these agglutinated cocci are
phagocytosed, or immediately if leucocytes have been brought artificially
into the cavity by a previous injection of aleuronate. This process does not
actively kill the cocci, but they probably die out within the leucocytes by
autolysis. The intracellular site of this autolysis accounts for the immunity
of the animals against poisoning. After intravenous injection the same
agglutination and phagocytosis occurs within the blood-stream, especially in
the capillaries where the cocci are impacted.

The protective action of the serum is thus due both to agglutination
and opsonization, the agglutinated cocci being more easily caught than if
they remained as single units. The subsequent autolysis of the cocci, taking
place within the leucocytes, does not lead to an intoxication of the animal.
The endotoxic extracts of Kraus owe their toxicity to debris of meningococci,
and the protective action of serum is due to an agglutination and phago-
cytosis of the d(^bris. P. F.

WAiiiiGBEir, Abvid. Acute leukaemia in pregnancy ; an argument against
the theory of infections origin of the disease. Acta med. Scandinavica, 1920,
54, 133.

A very interesting and well-reported case of the rare combination of
acute leukaemia complicated with pregnancy. The patient, aged 29,
developed on October 28, 1919, a pain in the gums and observed a discoloured
patch on the mucous membrane. The patch increased and she felt weak,
and by November 6 was admitted to the Surgical Clinic in Upsala with the
diagnosis of noma. A large lesion was found involving the gums and tongue,
but there was no enlargement of glands or spleen. A blood examination
showed 4,070,000 red corpuscles, 70 per cent, of haemoglobin, 10,800 leucocytes.

i j

PATHOLOGY AND BACTERIOLOGY 65

of which 6.2-4 per cent, were of the large mononuclear (lymphoblastic) type.
The neutrophils had sunk to 1-2 per cent. A few myelocytes were also
seen. From the sudden onset, the gangi-enous stomatitis, the fever, and the
blood-picture the diagnosis of acute leukaemia was made. Of great interest
is the fact that a year and a half prexiously she had suffered from
haematemesis and several blood counts had been made, the last of which, on
March 26, 1918, i.e. 19 months prior to the present illness, showed only an
anaemia. She had been quite well until October 28, 1919. Daily
examinations of her blood were made and showed a prog)-essive deterioration
from the count given above (November 6) until November 20, when the
figures were 900,000 reds, 30 per cent, haemogloljin, 48,000 leucocytes, of
which lymphoblasts numbered 87-8 per cent., lymphocytes 11-2 per cent.,
neutrophils 1 per cent., eosinophils 0-2 per cent., and myelocytes 0-2 per
cent. On November 10 the patient, being in the 8th month of pregnancy,
was delivered of a female child, and although there was some temporary
improvement in her condition she died 11 days later. At the necropsy the
clianges in the viscera were slight, there was no enlargement of lymphatic
glands. The marrow was of a pale brownish-red gelatinous appearance, and
was mainly composed of large round non-granular cells of a lymphoblastic
type. The normal structure of the lymphatic glands was obscured owing
to the extensive infiltration of lymphoblasts among which some eosinophilic
myelocytes were also found. The hepatic capillaries contained many
lymphoblasts which were also found infiltrating the capsule of Glisson. The
normal structure of the spleen was obliterated by the lymphoblastic and
myelocytic infiltration. The necrotic part of the tongue was not infiltrated.
A searching examination of the tissues and organs of the child led the
author to the conclusion that they were normal, at any rate not leukaemic.
The author was able to find only three similar cases in the literature, viz.
those of Askanazy (1893), Petersen (1914), Lindbom (1919), and he regards
this as pointing to a non-infective origin of acute leukaemia.^ Reference is
also made to the possible occurrence of acute leukaemia in newly-born
children as reported by Pollmann (1897) and Lomell (1905). In both these
cases the mothers were not affected with the disease. Obrastzow (1890) has
recorded a case of acute leukaemia in a nurse who, shortly before, had
attended a patient who died of the disease. W. B.

McIntosh, J. Transmission of experimental encephalitis lethargica in
series in monkeys and rabbits, with notes on a spontaneous infection in a
monkey. Brit. J. Exper. Path., 1920, 1, 257.

The successful transmission in series of experimental encephalitis
lethargica to monkeys and rabbits has completed the experimental proof
necessary to show that the disease is caused by a living virus. The
spontaneous case recorded above is additional proof. In the second passage
the inflammatory lesion was not quite so strictly localized. This is appar-
ently due either to some change in the virus or to the lesion not being so
advanced. The greater involvement of the cord is in keeping with the more
diffuse nature of the brain lesion. -P- ^ •

IV.

66 ABSTRACTS

Gbamen, K. Om Wildbolz" egenurin-reaktion for konstaterande av aktiv
tuberkulos. [Wildbolz's auto-urine test for active tuberculosis.] Hygeia,
1920, 82, 673-781.

Gramen has carried out Wildbolz's auto-urine reaction on about 40 cases
of surgical and about 10 cases of pulmonary tuberculosis at the St. Goran's
Hospital in Stockholm. Some healthy persons were used as ' controls '. In
about 20 cases of definitely active tuberculosis, the reaction was positive,
irrespective of the site of the tuberculous lesion. Among the cases in which
surgical tuberculosis was more or less latent, the reaction was negative in
about 50 per cent., and doubtful or faintly positive in the remainder.
In some cases in which the disease was apparently healed, and also in some
of the healthy ' controls ', the reaction was positive ; but Gramen discounts
this evidence against the reliability of the test, pointing out that absence of
clinical symptoms in apparently healthy persons does not exclude activit}^
of a small focus of tuberculosis. His verdict on the whole is confirmatory
of Wildbolz's findings. C. L.

MAXTLAirD, H. B., Cowan, Maby L., and Detwezleb, H. "K. The aetiology
of epidemic influenza: experiments in search of a filter-passing vlruB.
Brit. J. Exper. Path., 1920, 1, 263.

During an outbreak of epidemic influenza at Toronto in the spring
of 1920, 17 typical cases and 10 healthy controls were investigated to
obtain evidence regarding a filter-passing organism as the cause of the
disease. Whole blood, filtered plasma, filtered laked corpuscles, whole and
filtered sputum and nasal washings, filtered empyema fluid, and filtered
tracheal mucous membrane were used for animal inoculation. Guinea-pigs
were principally used, but rabbits and mice also. Mice were found unsuit-
able. After inoculation the guinea-pigs and rabbits did not become ill, but
showed, when killed, a constant type of haemorrhagic lesion in the lungs
which has been described by Bradford, Bashford and Wilson, and Gibson,
Bowman, and Connor, and construed by them as indicating experimental
influenza in animals. There was also present a proliferative endothelial
change as mentioned by the former group of authors. It was not always
apparent to the naked eye, and was evidently of different origin from the
haemorrhage, although sometimes associated with it. By reinoculation with
filtered blood and lungs from such abnormal guinea-pigs, these lesions were
repeated up to seven reinoculations. The same lesions and the same per-
centage of affected animals were found after inoculation with filtered blood
from healthy persons. They were also present in apparently healthy guinea-
pigs from their stock and breeding pens and in pigs that came to them from
other laboratories, none of which had been inoculated. Attempts to obtain
cultures of a filter-passing organism by special methods were unsuccessful.
The animal lesions reported have no relation to the aetiological agent of
epidemic influenza in man. Their aetiology is uncertain and is being
investigated. P. F.

Wolf, C. G. L. The influence of the reaction of media and of the presence
of buffer salts on the metabolism of bacteria. Brit. J. Exper. Path., 1920, 1,
288.

The effect of moderate concentrations of disodium hydrogen phosphate
(3 per cent.) on the growth of B. coll, Vibrion septique, B. ivelchii, B. sporo-

PATHOLOGY AND BACTERIOLOGY 67

geiies, and B. histolyticus in _o-lucose peptone has been investigated. The
efFeet of acid potassium phthalate and sodium pyrophosphate on the growth
of B. coli was also ascertained.

In all cases the bufier salt either partially inhibits gas production
or produces a lag. If the fermentation be very prolonged, the volume
of gas may finally approach that obtained from a non-buffered medium. The
effect of phosphates on gas production is most pronounced in the case
of actively saccharolytic organisms, but is also definite with proteolytic
bacteria such as B. sjjorogenes and B. hidolyticus.

The effect of phosphates on the nitrogen metabolism is not pronounced.
On the whole the formation of amino-acids and ammonia from a medium
containing peptones, polypeptides, and amino-acids is not increased.

In the case of the saccharolytic organisms the acid production appears
to be increased when buft'er salts are added to the medium. This bears out
some of the results which have been obtained w4th similar organisms when
fermentation takes place in the presence of calcium carbonate.

The final reaction of the fermentations is affected by the presence
of buffer salts in the sense that in no case did the medium become so acid in
the presence of bufier salts as it did when these salts were absent.

The toxin formation in Vibrion se^ptique cultures is influenced by the
presence of a buffer salt— sodium phosphate. The toxin had a higher
potency than the control made without the salt. It is shown that toxins
may be kept potent for long periods of time in the presence of sodium
phosphate under conditions which would quickly destroy the toxicity of
a product made in an unbufiered medium. 16 P. F.

CoLtip, J. B. The effect of surgical anaesthesia on the reaction of the
blood. Brit. J. Exper. Path., 1920, 1, 282.

(1) The rate of elimination of water, acid and basic phosphates, and
ammonia by the kidney, in periods before, during, and after anaesthesia, has
been determined in a number of cases. (2) The acidity of the urine as
estimated by this method is not materially altered during surgical anaesthesia.
(3) A decrease in the C„ of the blood during surgical anaesthesia is not
indicated. (4) The acidity of the urine may be decreased during anaesthesia
liy the induction of hyperpnoea. (5) It is suggested that during surgical
anaesthesia two processes, which are mutually antagonistic, are active, one
the ' acidotic process ' of Haggard and Henderson, due directly to disturbance
in metabolism as a result of anaesthesia, the other the ' over- ventilation pro-
cess ', Whether the Ch of the blood falls, rises, or remains unchanged during
surgical anaesthesia would therefore depend upon the relative intensities of
these two processes. (Ch is the hydrogen-ion concentration). P. F.

TuRNBULi., H. M. Glycogenic infiltration of the liver of laboratory
rabbits. Brit. J. Exper. Path., 1920, 1, 310.

The histological changes seen in ordinary microscopic preparations of
the rabbit's liver when infiltrated with glycogen after a suitable meal resemble
closely those of a severe parenchymatous degeneration. The danger of
mistaking in animal experiment these physiological changes for manifesta-
tions of degeneration is illustrated by an account of the findings in a series
of experiments in which pairs of rabbits were inoculated respectively with

F 3

ABSTRACTS

contaminated water and with salvarsan dissolved in contaminated water.
Incidentally, attention is drawn to the promising field offered by glycogenic
infiltration of the liver of the rabbit for the experimental study of changes
in the nucleus during physiological activity of the hej)atic cell.

P. F.

MsNTEir, Sil. L. Variations in the benzidin peroxidase reaction depend-
ing on fixative, physiological activity, and type of animal. Brit. J. Exper.
Path., 1920, 1, 225.

(1) The Graham benzidin peroxidase reagent, consisting of a 0-5 per
cent, solution of benzidin in 75 per cent, alcohol plus 0-2 per cent, hydrogen
peroxide, produces a yellow-brown colour in the granules of mj-elogenous
cells in human blood, and is diagnostic for man. (2) The polymorphonuclear
leucocj^tes of blood of lower animals studied differ from those of human
blood in their reaction to the Graham reagent in that only a small percentage
of them develop the characteristic yellow colour. These positively reacting
cells are probably eosinophilic. (3) In a 0-5 per cent, solution of benzidin
in 75 per cent, alcohol free from hj'drogen peroxide practically all of the
myelogenous cells of the guinea-pig, dog, white mouse, white rat, and rabbit
give the characteristic coloured granular reaction. Addition of hydrogen
peroxide to this solution tends to inhibit the development of the yellow
colour, which disappears from all except one or two cells when the concen-
tration of the peroxide is increased to 1 per cent. (4) Bj^ varying the
concentrations of the alcohols in the Graham reagent a series of colours
ranging from deep brown through the j^ellows and the yellow-greens to blue
may be obtained in granules of human pus aspirated from empyemic cavities.
As these samples of pus age the colour reactions are lost. Pus in which the
leucocytes become more degenerated give a negative reaction. (5) The blue
reaction of pus-cells may be duplicated by exposing blood-films to weak
concentrations of acid, previous to treatment with benzidin solutions.

P. F.

Russell, B. E.. G., and Woglom, W. H. The respiratory exchange of sur-
viving mouse tissues, normal and neoplastic. Brit. J. Expcr. Path., 1920, 1,
244.

Respiratory quotients were obtained for surviving normal and tumour
tissues of the mouse by suspending emulsions in alveolar air in the Barcrof t
blood-gas apparatus. The results agreed very closely in successive experi-
ments with each normal tissue. Greater variability was found with
tumours.

Normal.

Tumour.

Kidney ....

. 0-883 + 0.002

t 1 37 S .

. 0.941 + 0-010

Liver ....

. 0.813 + 0024

?.1 206 .

0-868 ±0.039

Mamma ....

. 0.914 + 0.027

2fl 63 .

0.818 + 0.014

Submaxillaiy gland

. 0.841 + 0.024

^p 72 .

0.951 ±0018

(Total embi-yo

. 1.3-1.1)

0.719 ±0.031

(Mouse embryo skin

. 1.0)

(S 4, 155 .

0.674±0.013

The tentative conclusion is drawn that the more rapidly growing,
undiflferentiated tumours draw their energy from carbohydrate, the more
slowly-growing from fats. P. F.

1 1

PATHOLOGY AND BACTERIOLOGY 60

Dbaostedt, L. R. The effect of Streptococcus hemolyticus infectiou on the
reaction of the blood of rabbits. J. Infect. Dis., 1920, 27, 452.

This investigation was carried out to determine whether there is
a change in the reaction of the blood during streptococcus infection, and
whether, if there is a change, it is of sufficient magnitude to play any part
in the course of the infection. Blood was collected from the marginal vein
of the ear of a series of 30 normal rabbits. It was oxalated, dialysed
throuo-h collodium sacs and the hydrogen-ion concentration of the dialysate
was determined by the method of Levy, Rowntree, and Marriott. The range
was found to be between Ph 7-6 and Pu 7-75. Strains of Streptococcus
haemolyticus were injected into a series of rabbits intraperitoneally, and
daily observations were taken of the general conditions, temperature,
weight, and reaction of the blood. The maximum acidity observed during
life was ?„ 7-3. When it is recalled that />'. haemolyticus can grow in
a medium with serum until the acidity reaches Ph 4-63, the author concludes
that the development of acidosis per se in an acute infection can play no
inhibitory part in the progress of the infection. W. B.

Meadeb, p. D., and Robinson-, G. H. Biological and physical properties
of the haemotoxin of streptococci. J. Exper. M., 1920, 32, 639.

The production of haemolysin (haemotoxin) by certain streptococci has
been the subject of a great deal of experimental study. The present authors,
working with streptococci obtained from cases of empyema, have investi-
gated particularly the effect of filtration, adsorption, centrifugalization, and
shaking on the haemotoxin. Likewise they studied the influence of the
composition and the reaction of media on the production of haemotoxin.
They consider that it is a labile substance affected detrimentally by filtration
or by shaking. It is adsorbed by both organic and inorganic compounds.
It is obtained from bouillon having a Ph value, at the time of testing, of
7-2 to 5-3. The authors consider that it exists free in the culture medium
and that for its production two substances, at least, are necessary. One is
phosphorus, while the other was not determined with precision. The
unknown sul)stance was present in considerable quantity in blood-serum
and infusion of kidney, but it was neither albumin nor globulin metaprotein,
primary or secondary protease nor peptone of the medium. The substance
was found to be removed to a considerable extent by filtration through
kieselsruhr. W. B.

Gay, F. p., and Morrison, L. F. Experimental streptococcus empyema.
II. Attempts at dye therapy. J. Infect. Dis., 1921, 28, 1.

In a previous communication (vide Medical Science, 1920, 2, 357) one
of the present authors, Gay, in association with Stone, described the
experimental production, in rabbits, of empyema from the injection of
Streptococcus pyogenes and the production of an active immunity from the
use of vaccines. Continuing this line of work the present paper of Gay and
Morrison deals with the bactericidal action of dyes on streptococcus, and
especially the therapeutic value of dyes which exhibit powerful bactericidal
properties in vitro. Thirty different dye-stuffs were tested for bactericidal
powers on streptococci in broth culture as well as in pus. Eight of these
in dilutions of 1 : 20,000 or more killed the cocci in both fluids. The
bactericidal titre was greater in broth than in pus with two exceptions.

70 ABSTRACTS

Acriflavin killed streptococci in pus in a dilution of 1 : 200,000, while in broth
the titre was 1 : 20,000 ; proflavin destroyed the cocci in both fluids at
a dilution of 1 : 200,000. Experimental empyema in rabbits was produced
by injecting 0-2 c.c. of a 24-hour-old broth culture of a passage strain of
Streptococcus pyogenes into the right pleiiral cavity. Between passages the
culture was kept in the ice-box. The therapeutic experiments consisted in
the injection of the dye into the pleural cavity on the day following the
introduction of the culture. The dyes employed were safFranin, janus green,
solid green, methadone blue, new fast green 3 B, and acriflavin. In spite of
the fact that the doses injected were larger than appeared to be theoretically
necessary to sterilize the pus, and although there was no evidence of
decomposition of the dye-stuff, the life of no animal thus treated was
prolonged. W. B.

Richards, J. H. Eacteriologic studies in chronic arthritis and chorea.
Part I. Arthritis. J. Bad., 1920, 5, 511.

This is a very abridged account of ' part of a study of chronic arth-
ritis undertaken to determine whether any constant cultural or immuno-
logic streptococcus was associated with this disease '. The investigator
defines, by exclusion, the type of joint affection dealt with, but by his own
definition the joints included constitute not one but many types of disease
as this is understood clinically. In all, 104 patients were examined. Blood
cultures were made in all these and Slreptococciis viriclans was identified in
14. No other bacterium was found, and the controls examined gave negative
results. The information with regard to this part of the investigation is
more complete than that given regarding any subsequent part. Controls
are not mentioned subsequently in the account of the investigation, and
even here it is not stated how many controls were employed.

Complement fixation tests were also done in the whole series. The
antigen used was the unkilled, thoroughly washed, salt-ground, bacterial
emiulsion, the dilution being determined by estimating their nitrogenous
content. Positive results were obtained in 68.

Cultures were taken from the fluid from joints in 54 individuals, this
being done during an acute exacerbation, and an attempt was made to
obtain fluid also from the periarticular tissues. Of these 54, Streptococcus
viriclans was isolated in 4, but no information is given of the presence or
absence of other organisms.

The faeces were examined by the Gram stain in all the cases. Strepto-
cocci were found in 42 and of these Streptococcus viriclans was identified in 4,

The gums of all the members of the series under observation M^ere
examined bacteriologically, the pus being obtained from a pyorrhoea or
from the socket of a freshly drawn tooth, and >S'. viridans was found to be
present in 50, Again no mention is made of healthy controls.

The tonsils, whose secretion was cultivated in all of the 104 cases, gave
a positive result for *S'. viridans in 40. Certain sinuses, the prostate, the
pelvis of the kidney, and the Fallopian tubes accounted for 9 positive
cultures of this streptococcus. Presumably the foci mentioned in the last
group were examined only in those individuals where the clinical evidence
pointed to the possibility of infection, but no definite information is available
on this point. The question is nevertheless an important one, as, not
infrequently, joint troubles co-exist with an accidentally discovered focus of
infection in one or other of these situations.

PATHOLOGY AND BACTERIOLOGY 71

The results, on analysis, are of themselves sufficiently remarkable, for
of 104 patients examined only 9 showed an entire absence of association
witli Streptococcus viridans. They are still more remarkable when we
consider the relative infrequency and lack of pathogenicity of this particular
micro-organism. They are, liowever, arresting, if we may infer that the
investigator's cases were taken indiscriminately in accordance with his own
classification, because this would not include only the so-called infective
type of chronic arthritis, that group to which some would confine the term
' rheumatoid arthritis ', occurring before middle life and showing many
affinities with other diseases of known bacterial origin. It would embrace
also not only types which, clinically at least, show very little evidence of
being infective, but even certain joint diseases which are almost certainly
non-bacterial. It is true that, in his introductory classification, the author
divides chronic arthi'itis into those cases which are ' non-bacterial in origin '
and those which are ' associated with bacteria in origin '. This, however, is
a mere begging of the question, for there is no definite proof that any
belong to the latter group with the almost sole exception of tubercular and
the gonococcal joints.

Further, if one judges by the recorded ages of the patients selected for
the purpose of this investigation, very few are included which belong to the
class already mentioned whose clinical resemblances to bacterial diseases
are relatively pronounced.

The report, however, is obviously a highly condensed one. Without
an accurate clinical description of each individual examined, in the existing
chaotic state of chronic joint classification, such records are not of very
much assistance either to the clinician or to other investigators.

R. S. W.

Avery, O. T., and Cullen, G. E. Studies on the enzymes of pneumococcus.
I. Proteolytic enzymes. II. Lipolytic enzymes : esterase. III. Carbo-
hydrate-splitting enzymes : invertase, amylase, and innlase. J. Exper. 31.,
1920, 32, 547, 571, 583.

The first paper is concerned with the study of the proteolytic enzymes
of pneumococcus. These enzymes are intracellular, and are capable of
hydrolysing (to some extent) intact protein, and especially peptones, the
latter with striking avidity. Sterilization as a rule was performed by
autoclaving for 20 minutes at 15 lb. pressure. Ph values were determined
colorimetrically, with the series of indicators outlined by Clark and Lubs.
Total nitrogen determinations were made by Kjeldahl's method, while
amino-nitrogen was determined by van Slyke's nitrous acid method.
Peptide nitrogen, viz. that in the— CO.NH — linkings was determined by
splitting them into amino-acids by hydrolysis and then finding the increase
in amino-nitrogen.

The optimum reaction for hydrolysis is Ph 7 to 7-8, which also
represents the optimum for the growth of pneumococcus. The terms
' protease ' and ' peptonase ' are used, but with no assumption as to whether
proteolysis and peptolysis are due to two separate enzymes or are two
activities of the same enzyme. Solutions of intracellular substance of com-
parable enzymic activity may be prepared by dissolving the bacteria in bile,
in sodium choleate, or by mechanical and autolytic disintegration of the
cell. The rapidity with which peptone is hydrolysed is proportional to the

72 ABSTRACTS

concentration of the enzyme. The enzyme is sensitive to heat ; an exposure
for 10 minutes at 100° C. destroys its activity. If the acidity is increased
to Pn 5, the acid death-point of pneumococcus, it suspends activity, but
does not destroy the enzjaiie, for the activity is restored by a readjustment
to Ph 7-8. Attenuation of virulence to one-millionth of its original strength
had no measurable quantitative effect on the enzyme activity.

In the second paper evidence is put forward to show that pneumococci
possess also an endolipase of marked activity. The substrate used to
demonstrate the lipolytic action was tributyrin. In no instances were
antiseptics used as preservatives in the digestion mixtures, while sterility of
all enzyme-substrate solutions was proved by subculture. The ordinary
method of adjusting the substrate to approximate neutrality with phenol-
phthalein, and then to determine by titration the amount of acid produced
by the enzyme action, was not adopted. The authors found the optimum
hydrogen-ion concentration for lipolysis, and then maintained this reaction
by suitable buffer solutions. This buffered substrate maintains optimum
conditions for enzyme action with a minimum of inhibition due to the acid
products of hydrolysis. The enzyme -containing solutions were obtained by
dissolving pneumococci in bile, or by extraction by other means. The
optimum reaction above mentioned was about Ph 7*8, agreeing again with
the optimum for the growth of pneumococcus. If the enz3^me is heated for
10 minutes at 70° C. its activity is destroyed. Attenuation of the virulence
of the pneumococcus had no measurable effect on enzyme activity. Enzyme
solutions preserved at refrigerator temperature retain their activity for
weeks. The possible relation of the endolipase to the mechanism of bile
solubility is discussed.

In the third paper the authors investigate the action of the intra-
cellular carbohydrate-splitting enzymes, amylase, invertase, and inulase.
The avidity with which pneumococcus attacks certain carbohydrates is
manifest in the accelerated growth and increased acid production of
organisms cultivated in the presence of these substances. Acids are produced
in culture media from starches and glucosides, as well as from mono- and
di-saccharides. The simple expedient of dissolving the bacterial cells in bile
and testing the resultant solution for the presence of enzymes as carried out
above for proteolytic and lipolytic activity was here found unsatisfactory.
This was due to the fact that bile in the concentration necessary to effect
bacterial solution inhibits completely the activity of the enzymes which
convert sugar and starch. As a result, the authors disintegrated the
pneumococcal cells by suspending them in balanced phosphate solution of
Ph 6-2, and hastening physical disruption by repfeated freezing and thawing
of the bacterial suspension. It was found that the enzymes present could
act on sucrose, starch, and inulin. Determinations of COo content were
made by van Slyke's apparatus. Qualitative tests for reducing sugar were
carried out with Benedict's solution, while qualitative determinations
were made by Benedict, by rotatory power, or by the gravimetric copper
method. The iodine colour test was used for the hydrolysis of starch to
dextrins. Sterility controls were used in all cases. The invertase and
amylase of pneumococcus are active within the limits Ph 5 to 8, with an
optimum at Ph 7'0. This range corresponds closely with limiting hydrogen-
ion concentrations which define growth of the organism in the presence of
carbohydrate. Attempts to determine the presence of an enzyme or enzymes
capable of fermenting dextrose and producing acid, an active characteristic

PATHOLOGY AND BACTERIOLOGY 73

of the growing cell, were unsuccessful. The authors conclude that the
enzymes described are not true secretory products of the living cell, but are
of the nature of endo-enzymes, since their activity can only be demonstrated
when cell-disintegration has occurred. W. A. M. S.

Thomsen, O., and Chbistensen, S. Bidrag til kendskabet af pneumococtyper.
[A contribution to the study of the types of pueumococci.] Jfosp.-Tid.,
1920, 63, 729-39.

Thomsen and Christensen have found by agglutination tests that the
types of pueumococci described by Americans as Types I, II, and III, are
identical with types occurring in Denmark. The marked differences between
these types were demonstrated on mice ; a highly virulent culture of
pueumococci was thought to belong to Type I only, as it was agglutinated
by I serum but not by II or III serum. It was, therefore, anticipated that
0-1 to 0*2 c.c. of I serum would protect against ()-05 to 0-1 c.c. of a 24-hour-
old, highly virulent bouillon culture. But the mice invariably died, and
the blood, spleen, and peritoneal exudate teemed with pueumococci.

It was found that all the colonies obtained from this source belonged
to Type III. Thus, the culture, supposed to contain only Type I, had
evidently become infected with Tj-pe III pneumococci : but these had formed
such a small proportion of the pneumococci in the culture that they showed
no visible agglutination by III serum. When a strictly pure culture was
obtained by Burri's method of culture from a single pneumococcus, then
0-2 c.c. of the corresponding serum protected mice against 0-05 to O'l c.c.
of a 24-hour-old bouillon culture.

To ascertain whether Type III was absolutely unattected by I serum,
solutions of 24-liour-old bouillon cultures of pure I and III types were made
up to 0-5 c.c. by the addition of 0-2 c.c. of I serum plus physiological saline
solution. Table I shows the effects of intraperitoneal injections of varying
quantities of Types I and III cultures into 16 mice. It was found that
0-2 c.c. of I serum protected against 0-05 c.c. of Type I culture, whereas
such a minute dose as 0-0000001 c.c. of Type III caused fatal infection,
acting in the same way as on mice given no serum. The conclusion drawn
from these experiments was that the various types of pneumococci are as
different from each other .serologically as the other micro-organisms to
be found in the sputum. Hence the necessity for type-specific serum in the
treatment of pneumococcal infections.

In order to learn how small a proportion of one type in a mixed culture
of Types I and III would be demonstrable by agglutination, solutions con-
taining the types in different proportions were made from equally dense
bouillon cultures of Types I and III, and were tested with I and III serum.
It was found that, when one type formed only 20 per cent, of the mixture,
it was incapable of agglutination, and this was not demonstrable till the
type in minority represented at least 40 per cent, of the mixture. When
the two types were present in equal quantities, agglutination was equally
well-marked with I and III serum. There was a tendency, demonstrated
in different ways, for Type I to outgrow Type III during passage from one
mouse to another by intraperitoneal injection. This difference in the
behaviour of the two types was shown by the following experiments.

Six mice were given intravenous injections of various quantities of Tj'pe
III. Six other mice were given intraperitoneal injections of the same

74> ABSTRACTS

quantities. It was found that the intravenous injections were considerably
less toxic than the intraperitoneal injections. But when this experiment
was repeated with Tj^pe I, there was no difference in the effect of intravenous
and intraperitoneal injections. This difference in the behaviour of Types I
and III was not demonstrable when highly \nrulent were replaced by
only slightly virulent cultures. Probably the greater resistance of the
mouse under certain circumstances to intravenous, as compared with intra-
peritoneal, injections may be traceable to the blood containing more bacteri-
cidal or growth-inhibiting substances than the peritoneal fluid.

Using Burri's method for isolating single pneumococci, Thomsen and
Christensen introduced into the peritoneal cavity of two mice 3 and 5 pneumo-
cocci respectively, belonging to Type I. Both micedied,af ter 2 days, of pneumo-
coccal septicaemia, with Type I in the blood. The same experiment with 5
and 4 pneumococci of Type III caused no infection. More than 4 or 5
couples of pneumococci could not be counted with accuracy, but it was found
that at least about 20 pneumococci, counted by Wright's method, of Type III
were required to provoke infection by peritoneal injection. These experi-
ments, again, suggest that a greater degree of virulence can be achieved for
Type I than for Type III. Type I differed markedly from Types II and III
in the slightness of the precipitation by its homologous serum of a bouillon
culture freed from bacteria by centrifugalization. The precipitation of
bouillon cultures of Types II and III by II and III sera respectively was
marked, that for Type II being slightly greater than that for Type III.

C. L.

Dumas, J. Sur la presence du bacteriophage dans Tintestin sain, dans la terre
et dans Teau. [On the presence of bacteriophage in the healthy intestine
in soil and in water.] Compf. rend. Soc. cle hiol, 1920, 83. 1314.

d'HebeIoXiE, T. (1). Sur le microbe bacteriophage. [On the bacteriophagic
microbe.] Compf. rend. Soc. de biol, 1920, 83, 1318.

d'HebelIiE, F. (2). Sur la nature du prineipe bacteriophage. [On the nature
of the bacteriophagic principle.] Compt. rend. Soc. de biol, 1920, 83, 1320.

BABI.ET, J. Sur le prineipe bacteriophage de d'Herelle. [On the bacterio-
phagic principle of d'Herelle.] Compt. rend. Soc. de biol, 1920, 83, 1322.

Debbe, R., et Haguenau. Quelques particularites du ' phenomena de
d'Herelle '. [Some peculiarities of the ' d'Herelle phenomenon '.] Compt.
rend. Soc. de biol, 1920, 83, 1348, 1368.

WoLLMAN, E. (1). A propos de la note de MM. Bordet et Ciiica. (Phenomene
de d'Herelle, autolyse microbienne transmissible de J. Bordet et M. Ciuca et
hypothese de la pangenese de Darwin.) [Concerning the note of Bordet and
Ciuca. (d'Herelle's phenomenon, transmissible microbic autolysis of
Bordet and Ciuca and Darwin's theory of pangenesis.] Compt. rend. Soc. de
biol, 1920, 83, 1478.

WoiiiiMAir, E. (2). Sur le phenomene de d'Herelle. [On the phenomenon of
d'Herelle.] Compt. rend. Soc. de biol, 1921, 84, 3.

SAI.IMBENI. Sur le bacteriophage de d'Herelle. [On d'Herelle's bacterio-
phage.] Compt. rend. Soc. de biol, 1920, 83, 1545.

The fundamental observations on which is based d'Herelle's idea of
the existence of a ' bacteriophagic ' microbe which produces a lysis of
B. dysenteriae Shiga have already been reviewed in this journal [Medical

PATHOLOGY AND BACTERIOLOGY 75

Science, 1920, 2, 182). In the same review attention was directed to the
work of Kabeshima, who disputed d'Herelle's main contention that the
'bacteriophage' was living, as he found that it sustained without injury
a temperature of 70° C. Kaheshima considered that it was probably of
the nature of a catalyst which caused nucro-organisms to produce autolytic
ferments, these ferments acting as catalysts to other bacteria. In this way
the lytic or bacteriophagic process can be carried on from generation to
generation. Twort, wlio was in fact the first to recognize the bacterio-
phagic phenomenon (1915), had a similar idea. Upon all new subjects in
science, a litej-ature, good and bad, rapidly accumulates, and this is now
happening with regard to the ' phenomenon of d'Herelle '. It is taking one
of two directions, (a) new facts illustrating bacteriophagic phenomena,
(6) new views explaining these phenomena. Some of the recent communi-
cations are here considered.

Dumas describes the bacteriophagy of B. dysenteriae Shiga and B. coll,
from products obtained from persons who never had intestinal disease.
He also found ' bacteriophage ' in the intestine of guinea-pigs, and, believing
it to be widely disseminated, examined and found it in soil and in different
waters. Thus, on adding 150 c.c. of water to 150 c.c. of bouillon and placing
the mixture in the incubator for 24 hours, he found that the filtrate from
a Chamberland bougie is lytic when tested on B. dysenteriae or B. coli.

d'Herelle (1), in a short note, defends his previous position in opposition
to Kabeshima, and maintains that the alleged solubility of ' bacteriophage '
in ether is not a reality. In a second note he considers in particular the
idea of Kabeshima that the action consists essentially of a catalyst and
a proferment, the latter being present in or produced by the bacterium,
while the former is derived from the host. d'Herelle thinks that the trans-
mission from generation to generation must be due to a living agent
endowed with powers of reproduction.

Debre and Haguenau examined 81 samples of faeces from 63 persons,
and, having prepared the bacteriophagic materials by filtration, as usual,
tested them on dysentery, paratyphoid, typhoid, and colon bacilli. In
6 cases of acute dysentery the intestinal filtrate was active three times.
In 16 cases of enteric fever it was also found three times. It was also
present in material from one case of diarrhoea, one of cancer of the stomach,
one of rheumatic fever, one of phthisis, and two cases of peritonitis. On
the other hand, Debre and Haguenau found no evidence of bacteriophage
in filtrates from the stools of infants healthy or ill, breast- or bottle-fed.
They also affirm that the bacteriophagic extracts are not always of the
same activity in different persons or even in one and the same person at
different times. Seventeen ' strains ' of bacteriophage studied by them were
all active on B. dysenteriae Shiga. While the bacteriophage acts in a
medium, such as bouillon or serum, it is inactive if applied to an emulsion
of Shiga's bacilli suspended merely in salt solution.

An important communication of Bordet and Ciuca on this subject has
been separately reviewed in this number of Medical Science. In a short
note Wollman recalls the resemblance between Bordet's views and the old
doctrine of pangenesis by Darwin. Salimbeni points out that facts, similar
to those established by d'Herelle, are known in connexion with myxo-
mycetes and myxobacteria, which only live in association with certain bacteria
and, having grown, cause lysis of the said bacterium. He cites the case of
Dlctyostelium mucoroides, which lives in association with B. Jluorescens.

76 ABSTRACTS

From cultures of D. mucoroides, Pinoy obtained a ferment which was lytic
for B. fluorescent. Salimbeni thinks that the d'Herelle phenomenon is
really due to some stage in the history of a pleomorphic organism. He
carried out observations on the lysis of B. dyseiiteriae Shiga by ' bacterio-
phage ', examining the changes induced in a van Tieghem chamber. He
found, in addition to the dysentery bacilli, a number of small, round or
slightly elongated bodies. The latter were often seen in direct contact
with the bacilli. They germinate and set at libertj'' small masses of proto-
plasm which for a time remain attached to the bacilli. Having ultimately
freed themselves, the protoplasmic masses enlarge and show one, rarely two,
vacuoles, and throw out pseudopodia and, as he affirms, become myx-
amoebae. These changes can also be studied in stained preparations.
Salimbeni provisionally suggests the name of Myxomyces skiga'phagus for
his myxamoeba. In a note A. Pettit states that Dumas, whose research is
referred to above, on examining his cultures in the light of Salimbeni's
report, found that a number of the tubes contained a myxamoeba.

In a later communication, Wollman (2) has made some interesting
experiments to determine the nature of d'Herelle's phenomenon. If one
add a trace of a living culture of Shiga's bacillus to a diluted bacteriolysate
it is observed that there is a great increase in the bacteriolytic power, and
this power is preserved for a long time, even in the absence of living Shiga
bacilli. Wollman then studies what the effect would be if the bacilli were
separated by a membrane which would be permeable to a ferment-like body
but impermeable to bacteria like B. dyf<erderiae. Such a membrane may
be made in the form of collodium sacs. These are prepared in the ordinary
way and are connected with a small glass tube plugged with cotton wool,
the sacs havino; been sterilized in water in the autoclave at 110° C. The
water which has diffused into their interior having been removed by a
pipette, is replaced by bouillon inseminated with a trace of B. dyseiiteriae,
and the charged sac is lowered into a tube of bouillon to which has been
added 10 di^ops of an active bacteriolysate. If one adds a drop of this
bouillon-diluted bacteriolysate to a living culture of Shiga's bacillus and
implants the mixture on agar, at once or later, areas of lysis make their
appearance. With very permeable collodium sacs charged with B. dyseii-
teriae in the interior, lysis takes the place of the bacilli, from which,
it is contended, there must have been a passage of the bacteriophagie
element through the collodium. In the interior of the sacs Salimbeni is
stated to have found elements such as he had previously reported.

With less permeable sacs (4 per cent, collodium) employed in the same
manner as above, it was found that the bacteriophage in the bouillon, i. e.
outside the sac, increases in activity, l:)ut there is no lysis of B. dyseiiteriae
in the inside of the sac, a result which is interpreted as being due to the
fact that the bacteriophage has multiplied outside the sac but has not
penetrated into the interior. Wollman considers that this experiment
renders untenable the view that the process is a modification of the bacillus
as suggested by Bordet and Ciuca. W. B.

1 NiNNi, C. Eicerclie svdla flora del tenue intestine di piccoli erbivori, special-
I luente in rapporto alia presenza in esso del £. coli. [On the flora of the small
I intestine of small herbivora, with special reference to the presence in it of
\ B. colL] Fathologica, 1920, 12, 242.

Investigations were carried out on healthy and diseased guinea-pigs

PATHOLOGY AND BACTERIOLOGY -(1

and raljbits, and showed the following results : (1) the addition of 0*2 pur
cent, of glucose to 1 per cent, peptone water is sufficient to obtain a pro- jjjf/l/}/,
duction of indol in 24-hour cultures of B. coll. (2) Such an addition allows /' / '^yJ
one to ascertain the presence of B. eoli in many instances (stomach of'
liealthy guinea-pigs and rabljits) in which it would have not been identified
by means of the ordinary methods. (3) BaciUus coli, which cannot be
identified by any means in the duodenum of healthy guinea-pigs and rabbits,
is always found in irreat quantities if the animals are even slightly diseased,
•^ C.d.F.

Davison, W. Divisions of tlie so-called Flexner group of dysentery
baciUi. J. Exper. M., 1920, 32, 651.

The author briefly records the results he obtained in the examination
of a large number of strains of dysentery bacilli of the Flexner type. He
tried to group the strains by agglutination and fermentation tests, and
while aJTreeinii' with the recent Eno-lish workers that there are divisions of
the Flexner group, he considers that they are ill-defined and do not appear
to be sufficiently distinct to warrant the use of separate names. He tliinks
that all mannitol-fermenting dysentery bacilli should be called B. dysea-
teriae Flexner and the subdivision noted. The subdivision should be either
by carbohj^drate fermentation or by agglutination with monovalent rabbity
serum, but not by both, as they do not coincide. W. B.

Dz Macco, G. Sulla efficacia del nutrosio nel terreno nutritivo di Drigalski-
Conradi. [On the influence of nutrose in the culture medium of Drigalski-
Conradi.] SperimeniaJe. Arch, di Hot, 1920, 74, 71.

The author has studied comparatively the growth of B. typhosus,
B. ixiralypltosus A and B, B. cull communis, and B. clysenteriae (Shiga and
Flexner strains) in the Drigalski-Conradi culture medium prepared with
and without nutrose. From many painstaking measurements it resulted
that only the colonies, both superficial and large, of B. typhosus, cultivated
in Drigalski's agar with nutrose, are somewhat larger than those seen in
the same medium but without nutrose. All other bacteria investigated
grew into colonies of the same size. Hence the general conclusion that the
addition of nutrose to the Drigalski-Conradi medium is not necessary for
the irrowth and identification of the bacterial species mentioned above.

C. d. F.

Fred, E. B., and Petersout, W. H. The fermentation of xylose by bacteria

of the aerogenes, paratyphoid B and typhoid groups. J. Infect. Bis., 1920, l^

27, 539.

Teague and Morishima, among others, have shown that the pentose
xylose is fermented by B. typhosus without gas formation, by B. para-
typliosiis B with gas, and is not attacked by B. jMTatyphosus A. The
present authors have made a study of the actual substances formed, in-
cluding in their series of bacteria B. aerogenes, which also produces gas.
With this latter organism carbon dioxide and ethylic alcohol were found to
represent about 75 per cent, of the sugar consumed. The main products of
the fermentation of xylose by B. paratyphosiis B are formic, acetic, butyric,
lactic, and succinic acids, ethyl alcohol, carbon dioxide, and hydrogen, these
products representing about 92 per cent, of the original sugar. The

78 ABSTRACTS

feriiieiitation of xylose by B. ty2jhosus is far from complete, not more than
one-fourth of the sugar being attacked. Only small quantities of carbon
dioxide are formed. The greater part of the fermented xylose is repre-
sented by succinic acid, although alcohol, formic, acetic, and butyric acids
are among the other products. The medium employed in these researches
consisted of a fresh yeast water extract containing 0-5 per cent, dibasic
potassium phosphate and 0-5 per cent. Difco peptone. The amount of
xylose added was 2 per cent. W. B.

Ornstezn, M. Zur Bakteriologie des Schmitzbazillus. [On the bacterio-
logy of the bacillus of Schmitz.] Ztsclir. f. Hyg. u. InfektionsTirayikh., 1920,
91, 152.

During the war K. E. F. Schmitz described an organism closely
resembling B. dysenteriae Shiga, but differing from it in its ability to form
indol and in the fact that it is not agglutinated by Shiga serum. Schmitz's
bacillus also gained notoriety through the statement of its discoverer that
pure cultures underwent remarkable transformations in that they became
converted into B. typhosus, B. 'paraty2:)hosus B, B. dysenteriae Shiga, i?. coli,
B. coli Tiiutabile, B. faecalis alkaligenes, and even other bacteria. The present
author, Ornstein, has made an elaborate study of Schmitz's bacillus based on
the examination of 31 strains, 8 of which were isolated in the Hygienic
Institute in Frankfurt, where the work was carried out, while 23 strains
were obtained from Schmitz. The author considers that Schmitz's bacillus is
a well-characterized species, and in his hands none of the conversions into
typhoid or other bacteria, as described by Schmitz, occurred. In the course
of the investigation two bacteria were encountered which were liable to be
mistaken for the bacillus of Schmitz. The first of these is named by the
author Bacillus fallax, a name which has no standing, seeing that it was
already used by Weinberg and Seguin, 1915, for a thoroughly characteristic,
obligate, spore-bearing anaerobe. Ornstein's B.fcdlax differs from Schmitz's
bacillus in being able ultimately to ferment saccharose. It also turns
litmus whey of a deeper blue colour and is antigenically distinct. The
second newly-described micro-organism it is proposed to call Bacillus
inconstans on account of its variable behaviour in the presence of dextrose.
Occasionally it acts on this sugar with gas formation. At other times it is
unable to do so. Antigenically it is also distinct. On saccharose-fuchsin-
sulphite-agar plates B. fallax (Ornstein) and B. inconstans both show
mutations like B. coli onutabile. According to the author, Schmitz's bacilli
in the living state do not show acid agglutination although killed cultures
are very variable. B. fallax and B. inconstans as a rule both show marked
acid agglutination in living as well as in dead cultures. Difficulties were
experienced in preparing high grade agglutinating sera against Schmitz's
bacillus, although in the presence of such sera all the strains of the bacillus
behaved alike. Anti-Schmitz serum possesses complement-fixing properties
in combination with cultures of the homologous organism, but none in the
presence of B. fallax or B. inconstans. The experiments which the author
cites indicate that in all probability B. inconstans is not a well-defined
species. The pathogenic properties of Schmitz's bacillus on animals were
not striking. W. B.

PATHOLOGY AND BACTERIOLOGY 79

DoiiD, H., und FiscHEB, W. Ein Fall von natiulich erworbener, Ixizilliirer
Dysenterie beim Ilunde mit gleichzeitiger Schistosomiasis, Ankylostomiasis
und Filariosis. [A case of naturally acquired bacillary dysentery in the
dog with simultaneous schistosomiasis, ankylostomiasis, and filariasis.J
Centralhlf. JBalteriol. (&c.), Abt. I, 1920, 85, 198.

A report on the occurrence of bacillary dysentery in a young male
German pointer in Shanghai. The animal was observed to be ill and to be
passing mucus and blood in its liquid stools. An examination revealed the
presence of vegetative amoebic forms, eggs of Schistosoinain japirnlcum
and Ankylostomu.on, while in its blood microfilariae were found. On the
ground of finding amoebae, emetin was given subcutaneously, but the animal
became rapidly worse and died in a few^ days. At the autopsy typical
Shiga bacilli were found, the anatomical changes showing a diffuse acute
pseudo-membranous inflammation over the whole intestine, large and small.
The amount of actual ulceration was, however, comparatively slight. The
intestine was also infected with Schistosomuni and Ankylostomum, and
Dlrojilaria immitis w^as also found in the blood. Nephritis and hyper-
trophy of the heart completed tlie anatomical picture. Entamoeba his-
tolytica was not found. The authors suggest that the animal was probably
infected from human dysenteric faeces, as these dogs are extensively used
for Imnting game in the low-lying grossly contaminated ground of the
Yang tse and the Hwang pu rivers. W. B.

EiSEAMP, E. H., and Fabk, L. EI. Fate of micro-organisms introduced
into isolated loops of the intestine. J. Infect. Bis., 1921, 28, 67.

In this research dogs were employed. The abdomen being opened,
a ligature was placed round the duodenum immediately below the pylorus.
The duodenum was then flushed out w^th warm salt solution introduced
through a hypodermic needle inserted immediately below the ligature. The
salt solution having been gently forced along by a milking movement, a
20 to 30 cm. loop of the empty duodenum was isolated between ligatures,
the loop always including the bile and pancreatic openings. Jejunal loops
were isolated in a similar manner. Emulsions of various bacteria were
injected into the loops, and after gentle massage a control sample was
removed and counted for bacteria. The abdomen was then closed, and
after a period of 2 to 12 hours the animals w^ere killed and the contents
of the loops again examined to see what changes had taken place in the
numbers of the bacteria wdiich had been previously introduced. The results
were based on the examination of 26 animals. Many of the bacterial
cultures employed were of saprophytic type, but pathogenic organisms like
B. typhosus, 8. aureus, Streptococcus, and B. anthracis were also employed.
It was found that many of the microbes introduced had been destroyed.
By a study of the bacteria other than those experimentally introduced, the
authors concluded that the destruction is not due to any antagonism of the
bacteria normally found in the bow^el. They think, indeed, that there is
another and distinctive antibacterial mechanism, the nature of which, at
present, is unknown. W. B.

Beckwith, T. D., and Lyon*, R. H. The viability and growth of B.typbosus
in bile. J. Infect. Bis., 1921, 28, 62.

A very large literature exists on the eflfects of bile and bile salts on
members of the colon-typhoid group of micro-organisms. The present

80 ABSTRACTS

authors have again dealt with the subject, and have endeavoured to find
out whether B. typhosus is viable in bile and whether it can multiply freely
in this medium. Seven samples ot' bile were tested, five being human, one
from the rabbit, and one from the ox. Known quantities of typhoid
culture were introduced into bile, and plate-cultures were made at suc-
cessive intervals up to as long as 48 hours. The results showed that
B. typhosus is long lived in human, rabbit, or ox bile. Introduced into
sterile ox bile it is subjected at first to marked bactericidal activity on the
part of the medium, by which a large number of bacilli are destroyed.
This is followed by an evident lag, and finally there is a slow but pro-
gressive proliferation. W. B.

LiTCK, V. M., and Meyer, K. F. A spontaneous epidemic among labora-
tory rabbits caused by a paratyphoid B bacillus related to the rodent
group. J. Infect. Bis., 1921, 28, 27.

This is an account of a small epizootic, in laboratory rabbits, due to
a paratyphoid organism belonging to the animal paratyphoid group. The
details which are of interest to laboratory workers should be consulted in
the original. It may be pointed out, however, that the micro-organism
isolated did not belong to the human paratyphoid group from an anti-
genic point of view. The fact that it was able to produce a toxin may
be of importance in connexion with outbreaks of food-poisoning in man
from the consumption of rabbit. Hitherto the chief, if not the only,
instance of this has been the occurrence of paratyphoid in four persons,
including a child of 4 months, which was described by MacConkey in
1906 (/. Hyg, 6, 570). By cultural and agglutinating experiments he
showed that the microbe isolated from a piece of the suspected rabbit and
from the spleen of the child, who had only partaken of a small quantity of
the gravy, was closely related to B. aertrycke and B. paratyphosus B.

W. B.

Behmeb, W. Beitrage zur Biologie und Biochemie des Bacillus proteus und
Versuclie zur Isolierung pathogener Mikroorganismen aus proteushaltigem
Material mittels Agarplatten mit Karbolsaurezusatz bzw. Eichloffblauplatten.
[The biology and biochemistry of B. proteus and attempts at the isolation
of pathogenic bacteria from Proteus-contaminated material by means of
agar plates containing carbolic acid or Eichloff-blue.] Arch. f. Hyg., 1920,
89, 295.

The author made an exhaustive examination of 23 strains of Proteus.
The primary object of the work, however, was to elaborate a satisfactory
technique whereby various bacteria could be isolated from mixtures con-
taining Proteus. Hitherto the most satisfactory method has been that of
Schaetfer, who found that 2 c.c. of a 5 per cent, solution of carbolic acid per
100 c.c. of agar afforded a medium on which Proteus grew as isolated well-
defined colonies instead of spreading over the whole culture surface and
making isolation of other bacteria almost impossible. Carbolic acid medium
has, however, drawbacks, for certain bacteria will not thrive upon it. A
substitute is described by the author under the name ' Eichloff-blue '. This
term is meant to indicate that the medium is blue from litmus and is made
of an extract of a proprietary article, from skimmed milk, manufactured by
Eichloff in Greifswald. The medium is identical with that of Drigalski

PATHOLOGY AND BACTERIOLOGY 81

and Conradi except that, instead of meat extract, the extract of EichlofF is
employed. On ' Eichlotf-blue ' plates Proteus colonies are smaller than on
carbolic agar and are well defined, and it possesses advantages in that
certain organisms which will not grow on carbolized media will grow well
on the new medium suggested. B. anthracis will not grow on either
medium. W. B.

Amoss, H. L., Gates, F. L., and Olztsky, F. E. Simplified production of
antimeningococcic serum. J. Exper. M., 1920, 32, 767.

Tliis paper deals with attempts to produce a more efficacious anti-
meningococcic serum and considers the fundamental basis on which anti-
meningococcic sera have hitherto been prepared. It is now thoroughly well
established that the general term meningococcus really covers a group of
closely related micro-organisms and is not a fixed antigenic entity. So long-
ago as 1909 Dopter separated meningococci from parameningococci, and this
differentiation was further extended to two other groups by Gordon, who
separated four different types. The practical question from a therapeutic point
of view is whether antimeningococcic serum should be made with one or
many antigenic tj'pes. For example, the antimeningococcic serum of the
Rockefeller Institute has been made as polyvalent as possible, cultures to
the number of 51 having been employed in its manufacture. The present
authors have now studied antimeningococcic sera made with a few or
actually a single strain of meningococcus and have compared the agglutina-
tion reactions with those of the polyvalent serum of the Rockefeller Institute,
in which a laro-e number of strains have been utilized in the immunization.
They found that horses injected with an antigen limited to five, three, or
one strain of culture yielded sera with a range of agglutinins covering in
high dilutions practically all the stock strains used in making the polyvalent
serum.

Very striking difterences were observed, for whereas the agglutinating
power of the highly polyvalent serum remained unimpaired afiter storage
for a year, a monovalent serum fell off" greatly in this period, especially witli
regard to secondary or subsidiary agglutinins. A serum made with five
strains, viz. a regular meningococcus, a parameningococcus, and three inter-
mediate meningococci approached the Rockefeller polyvalent serum, and at
the end of a year still agglutinated 39 of 41 strains tested. Absorption
tests also brought out striking differences in the nature of the polyvalent
and monovalent sera which had appeared to be identical in simple agglutina-
tion tests. The homologous strain on triple absorption was able to exhaust
the monovalent serum completely, but was unable to remove from the
polyvalent serum agglutinins to which 30 out of 44 different strains were
able to react. In addition to specific agglutinins, a monovalent serum
contains a wide range of common or secondary agglutinins, but these tend
to disappear on keeping. The difference between specific and secondary
agglutinins is only apparent in absorption tests. In a serum produced by
the injection of a large number of strains the agglutinins are mostly specific
and differ in some way from the secondary agglutinins which make their
appearance in sera wliich have been produced with one or a few strains.
The authors did not determine whether the two types of sera had different
therapeutic powers. W. B.

IV. G

82 ABSTRACTS

Anderson, John F. An improved method for the production of anti-
meningococcic and other serums. J. Infect. Dis., 1920, 27, 482.

Hitherto the production of antibacterial sera has been associated with
considerable difficulties, among which may be mentioned the prolonged
period required and the loss of animals from toxic or other causes. The
author has had a large practical experience, and discusses in particular the
anaphylactoid phenomena witnessed in horses during immunization against
meningococci for therapeutic purposes. He appears to have got over
this difficulty by the use of antigens washed, free of poison, in salt
solution, the injections, which are intravenous, being made immediately after
the bacteria have been so treated. The severe and even fatal reactions
after intravenous inoculation are apparently due to the presence of some
toxic substance and are not really manifestations of a true anaphylactic
character. The scheme of immunization suggested provides for four
successive intravenous injections with intervals of three days, the treatment
being commenced with dead bacteria which after the fourth injection is
changed to living cultures. W. B.

De Witt.Lydia M. "Weight curves of tuberculous guinea-pigs. /. Infect.

Bis., 1920, 27, 503.

The authoress draws attention to the fact that in most of the experi-
mental work on the chemotherapy of tuberculosis the apparently beneficial
results of treatment are based on increased duration of life, favourable
influence on weight and diminished distribution and progress of the disease
in the animals employed. The present paper is an attempt to determine
whether the weight curves of guinea-pigs inoculated with tuberculosis
constitute a satisfactory basis for the expression of an opinion on the
therapeutic value of any drug. The weights of normal guinea-pigs,
tuberculous untreated and tuberculous treated guinea-pigs are given in
tables and in curves. Normal guinea-pigs of approximately the same age
and weight, and living under the same conditions run a uniform weight curve.
This curve is,' however, easily modified by changes in diet, acute infections,
and other variations in the conditions of life. Normal male guinea-pigs of
approximately the same age and weight, inoculated with the same doses of
the same strain of T.B. and maintained under the same conditions subse-
quently run a fairly uniform and typical weight curve. This may therefore
be employed in testing the effects of various methods of treatment and is
a more sure guide than the duration of life. Most therapeutic remedies
tested, even although so non-toxic that they did not exert an influence on
the duration of life, or on the weight curves of normal guinea-pigs, tend
to produce a material alteration in the type of the weight curve. This
alteration consists in the main of a diminution in height of the ascending
curve and an increase in length of the descending curve. W. B.

MetaIiNXKOW, S. L'immunite naturelle et acquise chez la chenille de Galleria
mellonella. [On natural and acquired immunity in the larva of Galleria
mellonella.] Ann. de VInst. Pasteur, 1920, 34, 888.

For a number of years Metalnikow has made experiments on the effect
of introducing diverse strains of tubercle bacilli into the larvae of Galleria
'mellonella — the bee moth. He described the existence of a powerful

PATHOLOGY AND BACTERIOLOGY 83

phagocytic mechanisiu liy means of which the creature was enabled to deal
with colossal doses, which were without etiect. Some of the more recent
work of Metalnikow and Fiessinger were reviewed in this journal (Medical
Science, 1920, 2. 575). There it was pointed out that Fiessinoer had shown
that althouo-h there was abundant evidence of intense phagoc3'tosis in the
larva, the tubercle bacilli were not necessarily killed, for after a sojourn of
eight hours in the larva they were still pathogenic for the guinea-pig. The
present communication of Metalnikow is virtually a resume of his previous
work with certain additions. He gives a full account of the phagocytosis
and capsule. formation whereby the tubercle bacilli become segregated and
immobilized, and he points out that the brown masses formed in this process
may persist from the larval to the imaginal state. With regard to the
destructive powers of the phagocytes, he quotes experiments on three guinea-
pigs inoculated with the contents of larvae which, five days previously, had
been injected with a large quantity of living T.B. Only one of the guinea-
pigs died of tubercle, and he thus infers that at least a portion of the
introduced bacilli must have been killed. Among other observations in his
interesting paper Metalnikow cites the fact that, although tetanus and diph-
theria toxins are powerless to injure the larvae, snake venom or ox bile, even
in minute quantities, are almost instantly fatal. Mammalian red corpuscles
were harmless, even of heroic doses. In spite of multitudes of experi-
ments Metalnikow has never found evidences of the formation of any
antibodies in the larvae operated upon. Although Proteus cultures are
extremely fatal to larvae, they are so only on injection into the interior of
their bodies. Animals infected with or dead from Proteus are incapable of
starting an epizootic when placed among the healthy. VV. B.

EOKGSTED, EI.XZABETH. Vergleichende Untersuchungen liber die Methoden
von Herman und von Ziehl-Neelsen zur Farbung von Tuberkelbazillen. [The
comparative value of the methods of Herman and Ziehl-Neelsen for stain-
ing tubercle bacilli.] CentralU. f. Bakteriol. (&c.), Abt. I, 1920, Orig. 84, 513.

In 1889 Martin Herman recommended for staining tubercle bacilli
a mixture of crystal violet, alcoliol, and ammonium carbonate. The violet
and alcohol constituted one solution and before use w^as added to the solution
of ammonium carbonate. Nitric acid and 95 per cent, alcohol were used as
the decolorizing agents. In 1908 Herman modified his method and
recommended a mixture of 1 part of a 3 per cent, solution of cr3'stal violet
in 95 per cent, ethylic alcohol and 3 parts of a 1 per cent, watery solution of
ammonium carbonate. The strain was heated for 1 minute at boiling-point.
Decolorization was brought about by 10 per cent, nitric acid, followed by
95 per cent, alcohol. As a counterstain, eosin (1 per cent.) was used. Many
workers have used this method as it stands or with trivial modifications,
and in general have found it gives a higher percentage of positive results than
the Ziehl-Neelsen method. The present authoress has employed it, along-
side the Ziehl-Neelsen method, in the examination of 1,2U0 specimens of
sputum of which 345 were positive. Of these 29 were positive only by
Herman's stain and 8 were positive only by the Ziehl-Neelsen method.
The number of T.B. in 136 specimens w^ere alike with both stains. In 125
cases there were most bacilli with Herman's and in 47 more with the Ziehl-
Neelsen method. W. B.

a 2

84 ABSTRACTS

LiCKTENSTEiN', STEPHANIE. Ein Fall von spontaner rroselituberculose. [A
case of spontaneous tuberculosis in the frog.] Centralhl. f. BaJcteriol. (&c.),
Abt. I, 1920, 85, 249.

In the course of experiments on frogs the authoress found one with
a nodule on the liver. Smears therefrom showed masses of acid-fast bacilli
like T.B. Pure cultures were easily obtained, and were found to produce
a miliary form of tuberculosis disseminated everywhere, although usually
more sparse in the lungs. Death took place in 3-8 weeks. Cultures were
also lethal in about 12 weeks to Molge cristata. There is a discussion on
the literature of frog tuberculosis. W. B.

BIOCHEMISTRY

Dbummond, J. C, and Cowabs, K. H. Researches on the fat-soluble
accessory factor (Vitamin A). VI. The effect of heat and oxygen on the
nutritive value of butter. Bio-Chem. J., 1920, 14, 734.

The authors corroborate the results reported in this number by
Hopkins by showing that destruction of fat-soluble vitamine takes place
through oxidation. C. G. L. W.

HoFEXirs, F. G. (1). The effect of heat and aeration upon the fat-soluble
vitamine. Bio-Chem. J., 1920, 14, 725.

Fats are purified in various ways in order to make them edible, and
some discussion has taken place as to the efiect of heat on their vitamine
content. The author shows that fat-soluble vitamine is quite resistant to
heat, withstanding a temperature of ISO"" C. for four hours if protected from
air. If exposed to a temperature of only 80° C, and air is bubbled through
the fat at the same time, destruction of the vitamine proceeds with con-
siderable rapidity. Even exposure of the fat in thin layers to the air at
room temperature results in its losing its capacity for promoting growth.
The vitamine is prone to oxidation by atmospheric oxygen.

C. G. L. W.

Hopkins, F. G. (2). Note on the vitamine content of milk. Bio-Chem. J.,
1920, 14, 721.

In his original paper on growth factors, Hopkins showed the effects of
adding quantities of milk so small that the}^ could not possibly influence
the total amount of food given, and therefore it was necessary to look for
some unsuspected substance in this type of food. Mendel and Osborne
found it difficult to repeat these results. On repea.ting his older results,
Hopkins found that there are certain seasonal variations which permit the
growth factor to be exercised at one time and not at another. Where the
difference comes in has not been definitely ascertained. C. G. L. W.

Stefkeitsozt, M. a note on the differentiation of the yellow plant pig-
ments from the fat-soluble vitamine. Bio-Chem. J., 1920, 14, 715.

A good deal of interest has been attached to the physiological signifi-
cance of the yellow colouring matters found in certain plants such as

BIOCHEMISTRY 85

carrots, which have been found to be identical with the yellow colours in
body fat, corpus luteum, &c. It has been suggested that this substance was
practically the same as the fat-soluble vitamine. In order to settle this
question Miss Stephenson prepared the colouring matter in a fairly pure
condition from a large quantity of carrots. This preparation proved
effective in promoting growth in rats. When, howevei*, pure carotene was
prepared from the roots and fed in the same concentration as above, growth
did not take place as in the first experiment, and the animals suffered from
keratomalacia. The removal of the yellow pigment from butter fat did not
interfere ^vi.th its growth-promoting qualities. While carrots contain
a irrowth factor, this substance is certainly not identical with carotene.

C. G. L. W.

ZiLVA, S. S. The action of ozone on the fat-soluble factor in fats. Bio-
amn. J., 1920, 14, 740.

Ozone inactivates the fat-soluble growth factor in fats. Ultra-violet
rays did not itnpair the activity of the preparation. C. G. L. W.

Drummond, J. C, GoLDZNG, J., ZiLVA, S. S., and Coward, K. H. The
nutritive value of lard. Bio-Chem. J., 1920, 14, 742.

Lard has always been signalized for its lack of fat-soluble vitamine in
contradistinction to other animal fats. The authors have endeavoured to
determine the cause of the deficiency, for it might be due to the nature of
the food used for fattening, or to the method of preparation for household
use. Five groups of animals were placed on diets with various vitamine
content. The final w^eights of the animals varied from 84 pounds on
a deficient diet to 150 pounds with a full diet with grass. After killing,
the fats from the slaughtered animals were incorporated in the diets of rats.
The fats from the deficient animals were deficient in vitamine. Those which
had received a full diet with grass contained a store of vitamine. The
deficiency is therefore partly due to the method of fattening in this country.
The second cause of loss is due to the method of manufacture of lard, which
is exposed in the process to high temperature and oxygen.

C. G. L. W.

Daniels, A. L., and LouGKiiiir, R. Deficiency of heat-treated milks.
J. Biol. CJicm., 1920, 44, 381.

The authors found that milk, if raised quickly to the boiling-point, and
kept there for one minute only, was quite adequate for growth. However,
they could not get normal growth in rats upon milk pasteurized for 35-40
minutes, or treated in other ways which involved rather prolonged heating.
As the vitamines (fat-soluble and water-soluble) seemed to be intact, they
looked for other deficiencies, and came to the conclusion that the error in
the milk, exposed to prolonged heat, was an inorganic one. The calcium
salts were rendered more or less insoluble, so that the animals were being
starved of calcium phosphates. The results are now being applied to infant
nutrition. R. A. P.

86 ABSTRACTS

McCann, W. S. An observation of the effect of a protein meal given to

a man at the end of an 8-day fast. Proc. Soc. Exper. Biol. ^- Med., 1920,
17, 173.

After a fast of 8 days a man was given a meal consisting of 350 grm.
of meat and 10 grm. of butter. Very low respiratory quotients were
obtained, viz. 0-687 and 0-681. These are what one finds in severe diabetes.
The author explains these quotients by assuming that the carbohydrate
portion of the protein is stored up in the depleted organism as glycogen.
In diabetes the glucose is excreted; under the above circumstances it is
stored up. C. G. L. W.

LusK, G. Additional experiments showing the production of fat from
protein. Proc. Soc. Exper. Biol. 6)- Med., 1920, 17, 171.

By direct and indirect calorimetric estimations it was shown that after
a Ifirge meal of meat a dog retained carbon which could only be deposited
in the form of fat. C. G. L. W.

Bradley, H. C, and Felsheb, H. Studies of autolysis. VI. The effect
of certain colloids upon autolysis. J. Biol. Chem., 1920, 44, 553.

There is always interest attaching to the process oi autolysis, by which
a tissue undergoes spontaneous disintegration after death. There is a
suggestive relation between autolysis and normal katabolism. The authors
have found that the autolysis of such substances as beef -liver is in general
markedly accelerated by acid. There are extant some observations by
Ascoli and Izar to the effect that colloidal sols of metals, such as silver and
gold, exercise a marked accelerating effect upon autolysis. These observa-
tions seemed to suggest an interesting relation between the colloidal state
and enzyme action, and appear to be an exception to the rule of acceleration
by acid. Unfortunately, upon repeating the work of Ascoli and Izar, the
authors cannot obtain any of the effects which they have reported.

R A. P.

TiSBAi.!., P. F. Estimation of the phenolic substances in urine. J. Biol.

Chem., 1920, 44, 409.

A good history of the research upon phenolic substances in urine is
given in this paper. Using an ether extraction method for the estimation
of the total phenolic substances in urine, results are obtained 50 per cent.
lower than those recorded by Folin and Denis. The amount of volatile
phenols (phenol and para-cresol) found by Tisdall's method agrees with the
values obtained by Mooser and Hensel. It is suggested that the discrepancy
between Tisdall's results and those of Folin and Denis is due to the presence
in the urine of unidentified bodies which react with their reagents. The
compounds are partly present in the free state and partly formed by the
action of strono- mineral acids on the urine. R. A. P.

Wish ART, M. B. Experiments on carbohydrate metabolism and diabetes.
III. The permeability of blood corpuscles to sugar. J. Biol. Chem , 1920,
44, 563.

The author finds in dogs no specific alteration of the distribution of
sugar between the blood-plasma and corpuscles in experiments with

BIOCHEMISTRY 87

different quantities and modes of administration of glucose, different degrees
of pancreatectomy and diabetes, lipaemia, acidosis, exercise, cold, or different
renal thresholds. The concentration of sugar in the corpuscles is normally
lower than that in the plasma, and holds for several animal species examined.
[It is curious that the author does not seem to be aware of a paper
published by Falta and Richter-Quittner (Medical Science, 1920, 2, 94), in
which it was shown that, normally, corpuscles contained no sugar. Sugar
passed into the corpuscles owing to a change of permeability produced in
the collection of the blood sample, unless it was collected by treating with
hirudin and pentrifuging rapidly. No mention is made here of the method
of collection.] R. A. P.

EiFF, H. A. Variation in the cholesterol content of the serum in pneu-
monia. J. Biol. Cliem., 1920, 44, 215.

The substance cholesterol seems to have a mysterious relationship to
many important body processes. For instance, diminutions in the cholesterol
content of the nerves have been found to occur in acute inflammatory con-
ditions ; there are further obscure connexions between the antitoxin and
antihaemolytic content of serum and the cholesterol content. The author
gives a rather full history of w^ork on cholesterol in these connexions. In
this contribution he has studied the cholesterol content of serum in cases of
pneumonia, using Bloor's methods. Though the figures show somewhat
large variations, there seems, in pneumonia, to be a fall in the cholesterol
content of the serum in the early stages of the disease. This is followed
by a rise in cholesterol content during the period of convalescence, and for
a short time after the period of resolution. Subsequently there is a return
to the normal. It is considered by the author that the primary decrease in
cholesterol is due to an absorption of the substance by the leucocytes and
subsequent transport by them to the seat of inflammation. Here it acts as
an antitoxic substance neutralizing toxins, and possibly exerting antigenic
properties. In ordinary acute toxic infections, the utilization of cholesterol
is proportional to the severity of the disease. The intervention of empyema
in pneumonia disturbs the normal serum picture. R. A. P.

Lewis, D. S., and Mason, E. H. The diastatic ferments of the blood.

/. Biol Chem., 1920, 44, 455.

Magendie (1846) showed that blood could split starch to dextrose and
glucose. In 1867, Michael Foster reported a diminished excretion of
diastatic ferment in diabetic cases, pointing out that the diastatic power of
urine was not due to bacteria. Diastases are universally distributed in the
body (pancreas, salivary gland, liver, blood, lymph, muscles, and kidneys).
After complete removal of the pancreas the blood diastase quickly drops,
returning, however, to its normal level in 4-5 days. This fact indicates that
the pancreas is not the only supplier of diastase in the body. The interesting
question is whether the blood diastase is connected with the hyperglycaemia
of diabetes and nephritis or whether its presence in the blood is to a certain
extent accidental. Research upon this point has been rather contradictory.
Several observers have found no relation between disease and blood diastase,
while others, such as Myers and Killian, have reported a series of diabetic
cases showing a close relation between the level of blood diastase and the
severity of the disease. The authors here find that the normal diastatic

88 ABSTRACTS

index is between 14 and 25, showing very little change in relation to food.
In diabetes, they cannot find any constant increase in blood diastase. In
cases of nephritis, though there are variations in the amounts of the
ferments, there is no real relation between the severity of the lesion and
the diastatic index, R. A. P.

McLisAir, F. C, IVEubbay, H. A., Jr., and Heitserson, L. J. The variable
acidity of haemoglobin and the distribution of chlorides in the blood.

Proc. Soc. Exper. Biol 6>- Med., 1920, 17, 180.

Completely deoxygenated blood was exposed to various tensions of
carbon dioxide, first in an atmosphere with oxygen present and then in an
atmosphere free from oxygen.

The whole blood was then analysed for oxygen and carbon dioxide free
and combined, and the serum analysed for carbon dioxide and chlorides.
The atmosphere to which the blood was exposed was analysed for carbon
dioxide and oxygen. The conclusion reached from the experiments is that
whenever the heterogeneous acid-base equilibrium is disturbed the new
equilibrium is established by the migration of acids in and out of the cells,
and about two-thirds of tliis acid is hydrochloric acid. The haemoglobin
displays diflerent degrees of acidity at varying oxygen tensions. The
buffer action of the serum under physiological conditions as compared with
isolated serum is increased at least ten times by the change in the acidity
of haemoglobin. C. G. L. W.

HORiucHi, Y. studies on blood-fat. I. Variation of the blood-fat con-
stituents of rabbits under normal conditions. II. Lipaemia in acute
anaemia. J. Biol. Chem., 1920, 44, 345.

Boggs and Morris showed how experimental lipaemia (increase of fat
in the blood) could be produced in rabbits by drawing 15 to 45 c.c. of blood
from them daily. This paper deals with the increase in the several fatty
constituents (including lecithin and cholesterol) induced in rabbits by small
daily bleedings and by one large bleeding. Rabbits fed on fatty and fat-
free diets have been compared. Bleeding caused a very large increase in the
fatty constituents of the blood ; in one case, that of an acute anaemia
produced by a single large haemorrhage of 45 c.c, the whole blood looked
like chocolate cream. With regard to the duration of this type of lipaemia,
a maximum is reached at the end of 72 hours after the bleeding. After
this, the blood fat declines. The author considers that the increase is due
either to food fat or tissue fat accumulating in the blood, support for this
view coming from the more ready appearance of fat in the blood in the
animal fed on a fatty diet. The increase in lipoids occurs in the plasma
and not in the corpuscles in the case of rabbits, a slightly difierent result
from that obtained b}^ Bloor when working on certain human diseases.
In explanation of the phenomenon, attention is drawn to a decrease of the
amount of lipase in blood-serum found by Sakai. Haemorrhage may
interfere both with the production of lipase by the pancreas and with the
lipolytic activity of the liver and other organs. R. A. P.

Imbie, C. G., and Graham, S. G. Fat content of embryonic livers.

J. Biol Chem., 1920, 44, 243.

The paper is a contribution to the question of the function of the liver
in fat metabolism. It has been found that when fatty infiltration of the

BIOCHEMISTRY 89

liver is produced by the injection of sucli substances as plilorrhidzin the
accumulating fat tends to be comparatively highly saturated, resembling in
iodine value the fat of the connective tissues. On the other hand the fat
entering into the structure of the cell has a high iodine value. This is
taken to mean that there is a mobilization of fat from the subcutaneous
tissues in these cases.

Using young guinea-pigs, Imrie and Graham have shown that at
a certain stage of embryonic development a fatty inliltration takes place in
the embryonic livers without change in the fat content of the maternal
liver, or difference in iodine value from the maternal liver fat. Consequently
such fat cannot have been mobilized directly from the tissues. An explana-
tion suggested is that the fat has been previously desaturated by the
maternal liver or other tissues. The fat is used within 2 or 3 days after
birth, and so is presumably a ready store. If tissue fat is mobilized in the
pregnant animal by the injection of phlorrhidzin, an accumulation of fat of
loiv iodine value (like tissue fat) accumulates in the embryonic liver. This
may be independent of any similar change in the maternal liver. The
experiments are s.uggestive, but do not really settle where desaturation of
fat in these cases takes place. R. A. P.

Lynch, V. Chemistry of the whitefish sperm. -/. Biol CJtcm., 1920, 44, 319.

Of the chemistry of the head of the spermatozoon not much is known and
is bound to be interesting ultimately from manj^ points of view. The dried
sperm heads of the whitefish were found b}^ Lynch to contain about 70 per
cent, nuclei and 30 per cent, protamine. All the phosphorus, 6 per cent...
was combined with the nucleic acid. The protamines gave a xanthoproteic
reaction, but did not give the test for tyrosin, cystin, or tryptophane. If
true, it would suggest that these latter amino-acids are not essential to life.

R. A. P.

CUZ.X.IS, W. C, and Hewsr, E. E. The ' ammonia coefficient ' of pregnancy.
Bio-Chem. J., 1920, 14, 757.

In a case of pregnancy terminating successfully without induced labour,
the ratio of ammonia to total nitrogen rose to 77*9 per cent. This ratio is
higher even than the well-known one of Nebelthau of 66 per cent. The
total acid part of nitrogen at the time was vevy small (2-1 grm.).

There appeared to be no relationship between the vomiting and the
coefficient. The results confirm earlier observations in the same field by
Ewing and Wolf {Amer. Journ. Ohst. 1907, 55, 289). C. G. L. W.

WiiiSOiT, D. W. Studies in pyrimidine metabolism. Proc. Soc Exper. Biol.
4- Med, 1920, 17, 179.

When uracil nucleoside is administered to rabbits there is often more
nitrogen excreted in the urine than can be accounted for by the nucleoside.
The same happens with a mixture of cytosin and uracil nucleoside.
Increasing quantities of uracil appear in the urine, or simpler complexes
containing the uracil gi'oup are fed. The conclusion may be drawn that in
the metabolism of yeast nucleic acids the pyrimidine group is early changed
in such a way as to yield urea. C. G. L. W.

90 ABSTRACTS

Barbour, H. G., and Babetz, L. H. Temperature changes induced by
gum acacia injections in normal and fevered animals. Proc. Soc. Exper. Biol.
4- 3Iecl, 1920, 17, 209.

The pyrexia induced by injection of pactopeptone and B. coH, and by
puncture of the corpus striatum, was depressed by the injection of solutions of
7-0 per cent, gum acacia. The effect is fleeting. A small rise in temperature
takes place in normal animals after its injection. C G. L. W.

MAI.TA1TEB, F., and Hofpe, E. N. Osmosis as a factor in the local
accumulation of leucocytes in the body. Proc. Soc. Exper. Biol. ^- 3Ied.,
1920, 17, 216.

Chemical forces have generally been held responsible for the chemotaxis
of leucocytes. It is asserted by the authors that the forces which come into
play are physical. Leucocytes were found to move in the direction of the
osmotic force and opposite to the direction of the difiusing substances in
solution. This motion is explained as being due to the greater permeability
of leucocytes for water, and the fact that their total mass is negligible as
compared to their content of water. C. G. L. W.

ChepIiIIT, H. a., and B.ettger, L. F. Studies on intestinal implantation
of Bacillus acidophilus. Proc. Soc. Exper. Biol. ^- Med., 1920, 17, 192.

B. acidophilus is found in the intestinal tract normally in very small
numbers. If two grammes of lactose or dextrin be given to rats for two to
six daj'S, a complete transformation of the flora takes place which is strongly
dominated by B. acidophilus. This also takes place with human subjects.
The administration of 300 grm. of lactose or dextrin led to an almost
complete suppression of all other viable bacterial tj'pes. The change may
also be brought about by giving milk soured by the organism. A non-gas-
producing flora is obtained thereby. The effect was much more pronounced
than with B. hulgaricus. C. G. L. W.

GuDEBNATSCH, J. F., and Bagg, H. J. Disturbances in the development
of mammalian embryos caused by radium emanation. Proc. Soc. Exper.
Biol. 4- Med., 1920, 17, 183.

By the injection of 5 millicuries of radium emanation, contained in
a small amount of saline solution, into pregnant and non-pregnant rats, no
monstrosities were produced, but a definite effect was seen on foetal and
placental tissue. The embryos are killed, and, instead of being aborted,
remain attached to the uterine wall and are gradually absorbed. When the
foetuses were removed peculiar haemorrhagic areas were noticeable along
the dorsal mid-line. These extravasations take place in the vessels of the
subcutaneous connective tissue and along the meningeal sinuses. Numerous
haemorrhagic areas were found in the uteri and especially in the ovaries.
Weak doses of radium emanation did not produce any macroscopically
visible efi'ects on the maternal tissues. The embryonic differentiating
tissues were affected. This fact may be of some biological significance, for
it is known that radium rays have a decided effect on fast-growing tumour
and cancer tissues. C. G. L. W.

MUEI.I.EB, J. H. Observations on bacterial metabolism. Proc. Soc. Exper.
Biol 4- Med., 1920, 18, 14.

By boiling a meat infusion with ' Norit ', a commercial decolorizing wood
charcoal, it will be found that the medium which was capable of growing

BIOCHEMISTRY 91

haemolytic streptococci no longer supports growth. By adding 1 per cent,
peptone to the treated medium growth again ensues. The substance in
question wliich is removed by the charcoal, is precipitated by mercuric
sulphate. The chemical nature of the substance has not been determined.

C. G. L. W.

Churchman, J. W. The cause of the parallelism between the Gram
reaction and the gentian violet reaction. The isolation of gentian positive
individuals from a suspension of a gentian negative organism {B. coli).
Relation of gentian violet reaction to dilution of implanted suspension.
The effect of repeated re-inoculations of gentian violet agar with gentian
positive organisms. The selective action of gentian violet in relation to
chemotherapy. The communal activity of bacteria. I'roc. Soc. Exper. BioL
4- Med., 1920, 18. 17.

The above six communications form an interesting study of the
separation of a strain which is usually looked upon as homogeneous within
fairly narrow limits. In the first paper it is shown that those organisms
which are Gram-positive do not grow in agar containing the dye. To this
rule there are about 10 per cent, of exceptions. An attempt was made to
train B. suhtilis to grow in media containing progressively increasing
quantities of the dye. This was unsuccessful. With a Gram-negative
organism {B. coli) an unexpected result w^as obtained. By stroking a
thick suspension of this organism across a divided gentian violet plate,
the growth w^as equally profuse on each side. If, on the other hand, a dilute
suspension was employed, the colonies on the gentian violet side became
progressively fewer with increasing dilution. Therefore, in a suspension of
a Gram-negative organism, only a small proportion of the individuals are
gentian negative. It is possible to isolate the gentian positive organisms,
and these are found to be perfectly Gram -negative. By cultivating the
various colonies on the plain side of a divided plate it is possible to isolate
from a gentian negative strain {B. coll) a gentian positive strain. There
may exist within a single bacterial strain, two types of individuals which,
though in every other characteristic identical, are quite dissimilar in their
reaction to gentian violet. These types retain the differential characteristic
after many transplantations. Further, if a colony which has grown on the
gentian violet side of the plate be cultivated and re-implanted on a divided
plate, far fewer colonies appear on the dyed side. The reason for this is
not clear. It may be due to some sort of communal property, which
enables bacteria, instead of pursuing individual careers, to aid each other in
their growth and thus accomplish in large groups what they cannot accomplish
singly. By repeated re-inoculation of a gentian violet plate with a Gram-
positive organism, growth will take place, which did not occur in the earlier
inoculations. Bacteriostasis is therefore a complex process, and any
attempt to transfer the selective action of a dye on bacteria as found in
laboratory trials to general therapeutics should take into consideration
the effect of mass of bacteria on the dye. A strain of B. coli was isolated
which was entirely fast to gentian violet and in large transplantations grew
perfectly. Individual cells isolated by Barbour's method never grew. This
would indicate that bacteria do not act as isolated individuals. They
possess the power, in numbers, of accomplishing effects which, alone, they are
incapable of. The nature of this community of action is at present im-
possible even to guess at. C. G. L. W.

92 ABSTRACTS

RADIOLOGY AND ELECTROLOGY

Radio -diag nosis.

Sessa, p. Contributo alio studio roentgenologico dei caleoli biliari. [Con-
tribution to the study of gall-stones by X-rays.] Bad'wl. med., 1920, 7, 345.

It is due to the study and research of English and American radio-
logists that our knowledge of biliary calculi and affections of the gall-
bladder has increased and become more assured. Having described in
detail his method and technique, the author discusses fully the difficulties of
seeing the shadows of biliary calculi owing to their transparency to rays,
and speaks of the differential diagnostic points. Two views, anterior and
posterior, are essential, and a lateral is very useful. Those who have tried
the gas insufflation method give varying opinions of its value. Many cases
and illustrations are given. The interesting point emerges that with similar
technique, apparatus as efficient and powerful as used by the English and
American workers, and plates as sensitive, the Italian radiologists do not
see as many gall-stone shadows as the former. The author has a percentage
of positive results of 10 to 12, which is little above that of his Italian
colleagues, but this does not compare with the figures of Knox, &c. The
suggested explanation of this difference is that of racial difference in the
patients, or perhaps difference in their food, so that the gall-stones are
either not produced or are of more transparent composition, though the
author does not advance this as more than a tentative suggestion.

N. H. M. B.

Camfo, G. Les methodes modernes pour diagnostiquer le cancer de restomac,
[Modern methods of diagnosis of cancer of the stomach.] Arch, de enfer-
medados del aparato digestivo, Vol. 2. (/. de radiol. et d' electro!., 1920, 4, 473.

Of all modern methods employed for the diagnosis of cancer of the
stomach, examination by X-rays and examination of the faeces give the
most convincing results.

Of the two radiological processes, radioscopj^' is superior to radiography
because it permits movements of the organ to be observed. Nevertheless
the photographic plate is often useful because it registers details too minute
to be recognized at sight on the screen. Therefore, in difficult cases, one or
two radiographs should be taken in spite of a previous radioscopic examina-
tion having been made. If a tumour exist anywhere in the gastric mucosa,
it modifies the shape of the organ by pressure on the mucous surface;
either an anomaly of the contour of the stomach is observed, or a light
zone on the dark base, according as the neoplasm is situated at the side of
the organ or entirely on its walls. In the second case the tumour is more
difficult to recognize ; in the first, normal obscurity is interrupted at the
point corresponding to the lesion and the space between the zone that one
sees and the zone which one should see, appears irregular and indented.
In certain cases a normal image is found, but of a very reduced size, indi-
cating total scirrhous infiltration : in other cases, the neoplasm, being less
prominent, does not greatly distort the image of the stomach, but rigidity

RADIOLOGY AND ELECTROLOGY 93

of the wall and interruption of the peristaltic movements are noticeable at
this point.

The commonest seat of <2^astric cancer is the pyloric ref;-ion ; in most
cases, the horizontal part of this reoion is invisible, because the retraction
is such that the very thin line of opaque salt which passes through the
stomach to the duodenum is not appreciable, either on the screen or on the
plate ; it is not rare, in cases of hard growths, to see the gastro-duodenal
orifice constantly open, and the opaque meal passing- immediately from tlic
stomach to the intestine. This accelerated evacuation may, however, exist
in non-malignant cases. In other cases there is true stenosis with a
characteristic image of dilatation.

It is also possible that an advanced p3']oric tumour may be invisible ;
this occurs particular!}^ when there is enormous dilatation produced hy
ulcerated stenosis of the pylorus which existed before the cancer or was
provoked by it ; a bilocular stomach may also be found. This form of
cancer is distinguished from the benign form of ulcer by the irregularity
and indentations of the retracted zone.

Hartext has shown, with the help of X-rays, the existence of cancer in
14 per cent, of cases in which it could not be diagnosed by palpation.
Reichel quotes 22 cases in which diagnosis was made solely by this method.
Rosanoft" considers it to he of extraordinary value in early diagnosis.

Of 172 cases examined by the author, 166 were directly visible by
radioscopy ; 6 were not visible ; in 93 the tumour was more or less appre-
ciable by palpation ; in 24 only resistance to palpation was noted ; and, in
55 cases, neither tumour nor resistance was apparent.

Without denying the immense importance of radioscopic examination,
the author does not consider it to be of sufficient value to justify the
exclusion of other means of investigation ; but it is a valuable method of
diagnosis and is often sufficient by itself. Examination must be repeated
several times if the result be negative or if it disagree with other signs or
suspicions. It is, moreover, a method to be emploj-ed carefully so as to
exclude any causes of error. S. U. L.-B.

Hadlobiology

MoTTBAM, J. C. The red cell content of those handling radium for
therapeutic purposes. Arch. Radiol. S,- Electrotk, 1920, 25, 194.

The cases were divided into (1) clinical and laboratory workers, and
(2) porters, clerks, &c., in the building. The former show a diminution in
the red cells, and a colour index about 1-2 ; the latter a smaller diminution
and a colour index about 1 -0. In three cases death followed a profound
anaemia : in these the blood-picture was that of an aplastic anaemia. In all
cases tliere was a marked polynuclear leucopenia and absence of signs of
regeneration. From these facts it is seen that the workers suffer seriously
and need all possible protection. P. L.-B.

MoTTBAM, J. C. Histological changes in the bone marrow of rats exposed
to the Y radiations from radium. Arch. Badiol. ^- Electroth., 1920, 25, 197.

Exposures varied from 12-460 hours : if over 48 hours the expo-
sure was carried out intermittently for 12 hours at night. A 12 hours'
exposure was equal to g^oth of a rad. Radiated specimens showed a

94 ABSTRACTS

diminution in numbers of young and darkly-staining nuclei and of nuclei
in the anaphase : also a diminution in the number of mitoses. Pene-
trating gamma-rays can apparently reach the bone marrow, whereas the
comparatively soft X-ra.ys cannot. P. L.-B.

MxiiANi, E. Azione antibatterica dei raggi secondari dei metalli colloidali.
[Bactericidal action of secondary rays from colloidal metals.] Radiol, med.,
1920, 7, 302.

The secondary rays must have a great importance in radiotherapy, but
their action has not properly been studied except in the series of experi-
ments made in Rome under the guidance of Prof. Ghilarducci during the
last few years. These have been based on liis theory of the relation between
wave length of rays and specific irritability of individual cells. In the
secondary or characteristic rays we have a scale of radiations with an
immense variety of wave lengths, which provides a means of studying the
specificity of their actions.

The present experiments were designed to test this activity in its
influence on bacteria, the source of secondary rays being colloidal prepara-
tions of metals and the bacilli B. prodigiosus.

(1) The colloidal preparation was held near to, but not in contact with,
the bacilli and irradiated.

(2) The colloid was added to the agar on the plate and the strips of
sown bacilli thereby irradiated.

(3) The colloid was added to a broth culture and, after irradiation, the
mixture was plated.

(4) The colloid was mixed with an emulsion of bacilli and the suspen-
sion was irradiated and then plated.

The results were generallj?- negative from the bactericidal point of
view when the secondary rays were from colloidal metals held close to or
added to the agar of the plate. When the colloid was added to a broth-
culture, or when the colloid and the suspension of bacilli were mixed, there
was a slight action in the form of delayed growth and altered staining.

In immediate contact with colloidal copper the bactericidal action was
more marked. It was first generated by rays of 13-14 W., and increased
with diminution of hardness of primary rays to 9 W.

In the fourth series the development of the bacilli was completely and
regularly prevented. With gold, silver, and palladium, at 13-9 \V., smaller
degrees of bactericidal action were seen. Complete arrest of growth could
not be obtained even by prolonging the duration of exposure.

Having discussed the nature of the rays given off" by irradiated metals —
characteristic, scattered, and corpuscular — the author considers their bearing
on the interpretation of his experiments. The bactericidal action was
ascribable to very soft rays only. On the other hand, a certain action
was produced by rays of varying hardness acting on copper, but the maxi-
mum effect — arrested development — was obtained only by using primary
rays of 9W. The partial results with the heavy metals may be due to
beta raj's.

These experiments have a practical value because the future of therapy
depends on the understanding of the problems of the possibility of giving to
each tissue raj'S of the appropriate wave length for its individual reaction.

N. H. M. B.

RADIOLOGY AND ELECTROLOGY 95

Radiothera'py

Menard. Trois cas de grossesse apres radiotherapie pour fibrome. [Three
cases of pregnancy after radiotherapy for fibroid. 1 Bull, et mem. Soc. tie
chh: de Fur., 1920, Feb. {Anh. cCdectrlc. med., 1920, 28, 219.)

The autlior declares it to be impossible to give a scientific explanation
of the action of X-rays on fibroids. Certain fibroids do not decrease in size,
while others completely disappear. He does not systematically seek the
menopause, as does Beclere. In certain cases that he has had under
observation a simple course of irradiation of the uterine mass caused the
haemorrhagce to cease.

(1) The patient, 43, had had four normal pregnancies. In 1915 the
periods became more abundant, from March 1916 she was never more than
eight days in the month without losing. Fourteen seances of radiotherapy
were held at intervals of from three to six days. The patient became
pregnant after six stances and the confinement was normal.

(2) The patient, 33, began treatment in October 1916. After seven
seances the periods became normal and lasted four days, then ceased.
Radiotherapy was continued, one seance per fortnight. In March she was
stated to be pregnant. The confinement took place normally in July 1917.
Pregnancy began when the uterus had been irradiated seven times, and the
eleven lollowing seances did not interrupt it.

(3) The patient, 32, began treatment in September 1918, and con-
tinued it at the rate of one seance per week. After 29 stances the periods
were normal and then ceased. In all, 39 seances were held, and in
September 1919 the patient was stated to be pregnant. Pregnancy began
after 29 irradiations and six further seances were given. The confinement
was expected in March 1920.

Menard thinks that it is necessary to irradiate the uterus while pro-
tecting the ovaries, although in certain cases the haemorrhage can only be
stopped by irradiation of the ovaries.

These three observations prove that it is often possible to save at least
one ovar}^ since the three patients became pregnant, and in the first two,
who came to term, menstruation reappeared at the usual interval after
parturition. S. U. L.-B.

Mabtindalz:, L. Intensive X-ray therapy versus hysterectomy for fibro-
myomata of the uterus. J Arch. Radiol. S,- Electroth., 1920, 25, 97.

In 39 per cent, of eases radiotherapy was the treatment.

The technique is that used at the gynaecological clinic of the Freibuig
University with slight modifications, due chietiy to the adoption of the
Coolidge tube. Cross-fire is employed through 20-22 ports of entry, through
18 ports over the abdomen, and 2 or 4 over the sacrum. The distance
between the anticathode and the skin is about 18cm. The exposure is
three minutes for each area with a Coolidge tube with hardness 8 and
4 milliamps : this is done on two consecutive days.

Physical signs and symptoms determine treatment as far as possible :
if the tumour were not larger than a six months pregnancy, were inter-
stitial, and menorrhagia the prominent symptom. X-ray was chosen. If the
patient could not undergo an operation, by reason of her health or occupation,

96 ABSTRACTS

X-ray was used. If the fibroid were small and causing no symptoms, no
treatment was undertaken.

In most cases there are no unpleasant effects.

In all cases of doubtful diagnosis, an exploratory laparotomy followed
by hystereetomj^ if necessary is the best treatment. P. L.-B.

Radium Thercvpy.

FxNCH, A. £. H. A report of the work carried out at the Radium Institute,
Loudon, from Jan. 1, 1919 to Dec. 31, 1919.

Malignant Conditions. Malignant growths vary somewhat in their
susceptibility to radium according to their nature, li D = QxT when D is
the dosage in milligramme-hours, Q is the amount of Ra bromide in milli-
grammes, and T is the length of exposm'e in hours, in general terms
epiblastic growths are more favourably influenced when Q is relatively low
and T high ; hypoblastic growths when Q is high and T low ; and meso-
blastic growths are in an intermediate position.

Except in cases of rodent ulcer all the cases are inoperable.

Carcinoma of the breast. In the encephaloid type the prog-nosis is
invariably bad. Prolonged screened exposures to the periphery occasionally
retard the progress of the disease. The atrophic type usually responds
well to prolonged screen exposures.

If the skin be ulcerated healing may often be induced by 12-18 hours
exposure with ' half strength ' applicators with 1 mm. silver screens.

Small isolated nodules are best treated by inserting an emanation tube
with 1 mm. silver screen from 18-24 hours. Prolonged screened exposures
are necessarj^ for metastases in liver, lung, &c.

Carcinoma of the uterus. In a few cases patients are treated to
diminish fixation and aid subsequent operation. Radium treatment appears
to exert a very beneficial effect upon carcinoma of the cervix.

In inoperable cases, definite benefit nearly always results, and the
progress of the disease is greatly retarded.

The most favourable cases are patients over 50 years of age with little
fungation and fixation ; but dissemination is always likely to occur.

Recurrences in the vaginal wall often do well if taken early.

In cases of cervical carcinoma of the cauliflower tj^pe, as much of the
growth should be removed as possible : a tube of not less than 100 mg. of
radium should be inserted with a screen of 1 mm. of silver or 2 mm. of lead.
A silver screen in contact with the vaginal wall for more than 18 hours is
likely to produce a fistula, but within the cervical canal this is not likely to
occur. The exposure should be 20-24 hours and may be supplemented by
a plate of 100 mg. or more of radium with a 2 mm. lead screen over the
fundus. Exposures should be repeated in not less than six weeks. Small
emanation tubes of 20-30 mg. initial activity with 0-3 mm. platinum
screen may be inserted into circumscribed nodules in the cervix for
12-18 hours.

Carcinoma of the body of the uterus. Hysterectomy should always be
performed if possible. If radium is used, a tube of not less than 100 mg
with a 1 mm. silver screen should be inserted into the uterine cavity, and
a plate of equal strength with 2 mm. lead screen, applied over the fundus.

RADIOLOGY AND ELECTROLOGY 97

Carcinoma of the tongue, 2Kilate, buccal and pharynijeal mucous mem-
branes. As a whole they do not respond well. For pro<;nosis they are
divided into two groups : (1) Those in wliicli acute ulceration predominates.
(2) Those in which induration predominates. The first class do badly ; the
second class respond better ; when the induration is circumscribed the
insertion of a tiny powerful emanation tube with 0-3 platinum screen for
5-6 hours brings about disappearance. Radiation of the cersical and sub-
mental glands should be carried out as a prophylactic measure.

Exuberant papillated growths on the buccal mucous membrane, if
taken early, often cleai- up entirely by the insertion of powerful emanation
tubes.

Prolonged screened exposures in cases of long standing lymphatic
infection with fixed and hard glands often considerably diminisli the size
of the glands and prevent ulceration of the skin over them.

Carcinoma of the rectum. Healthy rectal tissue is very susceptible to
radium rays, especiall}^ in men. The most suitable growths are annular
and situated in the upper half of the rectum : if the radium be placed in
the lumen of the gut no proctitis is set up. In the plaque-like type of
growth some proctitis almost invariably occurs. If there be extensive
ulceration a preliminary colostomy should be performed.

The routine treatment is the insertion of a tube of 100-200 mg. with
a 2 mm. lead screen for 15-30 hours : the dose should not exceed 3,000 m<j-.-
liours, and the exposure should not be repeated in less than two months.
Healthy mucous membrane must be protected.

Rodent ulcer. For this type of case radium is to be preferred to any
other form of treatment in an untreated ulcer of recent origin. Lesions up
to 3 cm, in diameter and not affecting bone or mucous membrane are almost
invariably removed by one application of from 1^-3 hours with a ' full
strength ' applicator unscreened. Treatment must be carried out well
beyond the edge of the lesion. The hypertrophic type will take a larger
dose than the ulcerative : with the latter it is advisable to give a larger
dose to the borders of the growth.

When affecting the palpebral mucosa, a rodent ulcer can usually be
eradicated by radium, but when the ocular conjunctiva is attacked the
prognosis is not nearly so good.

Rodent ulcers that have been previously treated with CO^, scraping, &c.,
need careful treatment owing to the devitalized condition of the tissues.
A prolonged exposure of 24-30 hours with a half-strength applicator and
2 mm. lead screen gives the best results,

A If bone has been attacked the affected portions should be removed
Defore commencing radium treatment.

, Carcinoma of the bladder. Treatment often gives good results,

[especially in females, both because of the easier introduction into the
bhidder and because a screened tube can be inserted in the vagina in appo-
sition with the trigone. A few cases of epithelioma of the female urethra
tave also been satisfactorily treated by the combined method.

Carcinoma of the 'prostate. If the disease be localized to one lobe a
jcreened silver tube should be buried in the mass, or a tube of 100 mg.
ictivity, with 1 mm. silver screen, is placed in the penultimate section of
a bicoude catheter which is introduced for 2 hours on five successive days.
This may be supplemented by an exposure over the perineum and also by
•^ tube introduced per rectum.

IV. H

98 ABSTRACTS

Carcinoma of the oesophagus. Definite, but only temporary relief may
be obtained : treatment should be carried out by a laryngologist. An
emanation tube of* not less than 100 rag. activity with a 1 mm. silver
screen should be used for 15-20 hours. Treatment must be continually
repeated.

Carcinoma of the stomach and intestines. Prolonged exposures with
heavily screened applicators sometimes diminish pain and arrest the pro-
gress of the disease.

Sarcomata. Periosteal usually respond better than endosteal ; myelo-
mata vary. Spindle-celled varieties respond best, round-celled not so
favourably, the large round-celled are intermediate. In melanotic sarco-
mata the primary growth may often disappear, but ultimately metastases
appear.

Sarcomata of the nasopharynx often disappear within a month of
treatment. Lympho-sarcomata attacking the cervical and mediastinal
glands usually show a marked improvement for a time, but repeated ex-
posures are needed at intervals for 3-4 years. Ultimately the disease gains
the upper hand.

Endotheliomata. Most frequently seen as a parotid tumour ; radium
treatment is often of value in inoperable cases. Unless all parotid substance
has been previously removed, prolonged irradiation with heavily screened
apparatus applied externally should be used.

Non-malignant conditions. In cases of uterine fibroids, treatment with
radium is very beneficial. The best method is to introduce a 100 mg. tube
with 2 mm. lead screen into the uterine cavity combined with applicators
of from 100-200 mg. similarly screened applied above the pubes for
24-30 hours. Treatment should be repeated. There may be a premature
menopause. The treatment of chronic metritis is the same.

Naevi. Treatment of cavernous naevi gives excellent results if taken
early. ' Half strength ' applicators with 0- 1 mm. lead screen should be
used, employing cross-fire. Exposure, 30-60 mins. on three successive days,
at about 6 weeks intervals.

Results in cases of capillary naevi vary ; idiosyncrasy is great. Not
more than 15 mins. exposure with a ' half strength ' applicator at first ; later,
exposures of 1-1| hours with 0-1 mm. lead screen. There is always a
tendency to the appearance of telangiectasis.

Corns, warts, 'painllom.ata, and keratomata can be removed by
exposures of 1-1^ hours with ' full strength ' applicators unscreened. Ten-
dency to recur is slight.

Keloids and vicious cicatrices. Radium treatment is better than
surgical : early treatment is essential. ' Half strength ' applicators with
1 mm. silver screen for 6 hours on 3 successive days.

Lwpus erythematosus. Often greatly improved. ' Half strength ' apph-
cators unscreened for 30-60 mins. at intervals of 4-6 weeks should be
used. Treatment should be carried well beyond the borders of the lesions.

Tuberculosis, (a) Lupus vulgaris of shin. If Finsen light fails, radium
often gives good results, especially when the mucous membrane of the nose
is affected. Tubes of 25-50 mg. with 1 mm. silver screen are applied inside
the nose with a ' full strength ' applicator with 2 mm. lead screen applied
externally ; exposure 6 hours. In ordinary skin lesions screened and un-
screened tubes are necessary, the former for indurated and the latter for
ulcerated areas.

PATHOLOGY AND BACTERIOLOGY 99

(b) Lupus vulgaris of palate and fauces. ' Full strength ' unscreened
apparatus for 30-60 minutes is generally followed by healthy scar tissue.

(c) Tuberculous adenitis. When the cervical triangles are affected
prolonged exposures with heavily screened applicators are recommended.
Pigmentation is very liable to occur.

Exophthalmic goitre. In early stages radium does good. Prolonged
screened treatment with 200-300 mg. is used. The first effect may be an
exacerbation of all symptoms for 2-3 weeks. In advanced cases great
caution is needed.

Leucovythaemia. (a) Splenic. Radium treatment is advisable as a pre-
liminary to operation. An exposure of 24-30 hours with 400-500 mg.
screened with 2 mm. of lead should be employed.

(b) Lymphatic. Radium treatment may improve the blood condition
and general health for a time.

Skin dit>eases. Radium does good in many chronic supei-ficial diseases.
' Half or quarter strength ' unscreened applicators are employed for
3-15 mius. every 2-3 weeks.

Arthritis deformans. Recent cases of a peri-articular type are often
benefited by the daily administration of 500 c.c. of radium emanation solu-
tion of a strength not less than 1-5 mc. per litre.

Report of the Chemico-Physical Laboratory. In preparing emanation
applicators certain precautions should be taken : (1) Strong fans should be
installed to prevent the inhalation of air diluted with emanation. (2) Rubber
gloves should be worn when working with mercury. (3) All tubes, &c.,
containing radium, should be kept as far from human beings as possible
when not in use.

A comparison of the various radium salts shows that only the sulphate
gives an efficient and permanent result. The explosion of tubes containing
radium salts is considered to be due to incomplete dehydration of the salt.

Report of the Research Department. The first communication dealt
with the great and rapid leucopenia produced by exposure to radiation and
the comparatively slow return to the normal when the worker is removed
from the influence of the radium. The second communication dealt with
ultra-violet radiation. Patients showing a spotty appearance under ultra-
violet radiation appear to be more susceptible to radium radiation than
those who are relatively unspotted. -P* L.-B.

Electrotherapy

DE KBArT, P. Action des courants 6lectriques sur les glandes .^ secretions
internes et les autres tissue. [Action of electric currents on the endocrine
glands and on other tissues.] Med. Eec, 1920, Jan., 136. {J. de radial et
d'electrol, 1920, 4, 431.)

High frequency currents in general application excite nutrition, destroy
toxins, augment the excretion of COg, increase the solid residue of the urine,
improve the nutrition of the skin, the hair, the nails, &c. In the forni of
diathermy they warm the blood and the tissues and dilate the capillaries ;
engorgement of the internal organs becomes less, and these are placed in
a condition of better nutrition. At the same time the internal secretion
glands become more active ; the most common proof of this being increased

100 ABSTRACTS

menstrual haemorrhage in the case of a woman. The author thinks the
secretion may be regulated ; strong local applications of diathermy on the
region of the implicated gland will prevent secretion, and small applications
will excite it.

He recommends effluvation for obtaining muscular contractions ; a
Tesla coil is joined up with an Oudin resonator; one pole is placed upon the
patient in the form of a large plate, the other is moved about all over
the body. Thus is obtained a better muscular tone, a greater sensation of
well-being, and a possible decrease in weight of 50 lb. in 60 stances.

In cases of obesity with disorder of the peripheral circulation, cardiac
weakness, enlargement of the abdomen, diminution of urine, the wave
current of the static apparatus applied to the abdomen, produces con-
tractions of striated and unstriated muscles, reduces congestion of the liver,
improves digestion, warms the extremities, strengthens the heart, and is
able to diminish the weight by 100 lb.

The galvano-faradaic-sinusoidal combination is very useful in diabetes,
gout, and in mental and nervous disorders. Applied from the back to the
abdomen it tones up the muscles of both, improves the general condition of
the body, benefits venous circulation (especially the portal) and lymphatic
circulation. Reduction of weight produced by dietetic treatment has
the drawback that it predisposes to displacement of the internal organs
by causing the disappearance of their fatty support without re-establishing
muscular support, while electrotherapy is free from this objection.

S. U. L.-B.

MEDICAL SCIENCE

ABSTKACTS & REVIEWS

Volume IV. Number 2 May 1921

CONTENTS

REVIEWS: tage

INTESTINAL PARASITES 103

DISEASES OF THE SKIN HO

DISEASES OF THE SPLEEN 118

BILIARY SURGERY 125

CONGENITAL TORTICOLLIS 132

INTESTINAL EXCLUSION 137

THE PHYSIOLOGY OF THE ELEMENTARY NERVOUS SYSTEM : ITS

BEARING UPON SOME MODERN NEUROLOGICAL PROBLEMS . 141

ABSTRACTS :

NEUROLOGY 1*^

PATHOLOGY AND BACTERIOLOGY 152

BIOCHEMISTRY 1*^^

RADIOLOGY l^X

MEDICAL RESEARCH COUNCIL

The viscount GOSCHEN, C.B.E. (Chairman)

WILLIAM GEAHAM, M.P.

The Hon. EDWARD F. L. WOOD, M.P. {Treasurer)

C. J. BOND, C.M.G., F.RC.S.

Professor WILLIAM BULLOCH, M.D., LL.D., F.R.S.

T. K. ELLIOTT, C.B.E., D.S.O., M.D., F.R.S.

HENRY HEAD, M.D., F.R.S.

Professor F. G. HOPKINS, D.Sc, F.R.C.P., F.R.S.

Major-General sir WILLIAM LEISHMAN, K.C.M.G., C.B., F.R.S.

Professor NOEL PATON, M.D., F.R.S.

SIR WALTER M. FLETCHER, K.B.E., M.D., Sc.D., F.R.S. {Secretary).

The Council are indebted to the following for editorial superintendence in
the subjects named :

Medicine . . . . J. D. ROLLESTON, M.D.

Surgery . . , . W. G. SPENCER, M.S., F.R.C.S.

Pathology and Bacteriology W. BULLOCH, M.D., LL.D., F.R.S.

Neurology . . . F. M. R. WALSHE, M.D. F.R.C.P.

Radiology . . . W. S. LAZARUS-BARLOW, M.D., F.R.C.P.

SIDNEY RUSS, D.Sc.

Biochemistry , . . C. G. L. WOLF, M.D.

All communications on editorial matters should be addressed to

E. SCHUSTER, D.Sc,
Assistant Secretaiy, Medical Research Council,

National Institute for Medical Research,

Haiaipst^ad, N.W, 3.

REVIEWS

INTESTINAL PARASITES

McLean states that intestinal parasites are infrequent in New York
City children living under good hygienic conditions. In examination by
him of 308 stools from children up to 12 yesbvs of age he found that only 7,
or 227 per cent., harboured parasites, viz. Ascaris htynbricoides or Oxyuris
vermicularis. In 4 the presence of parasites was determined by the find-
ing of ova, and in 3 by the presence of the parasites.

Under the name of the tongue sign, Couillaud describes an appearance
of the tongue met with in oxyuriasis and ascariasis, and characterized by
enlargement of the fungiform papillae which are seen in the form of red
points distributed over the margins of the anterior surface and tip of the
tono-ue. According to Couillaud this sign may appear by itself apart from
any other symptom of helminthiasis. On expulsion of the worms from the
intestine it rapidly diminishes and disappears entirely. While possibly
indicating a catarrhal condition of the intestine, the sign is more probably
due either to toxaemia or to slight and repeated irritation of the intestinal
mucosa with reflex involvement of areas innervated by intermediate bulbar
centres.

According to Neumann, who records two cases of oxyuriasis and one of
ascariasis in infants, intestinal parasites, while very frequent in older children
and adults, are rarely met with in infants. He quotes Israilten, who made
investigations in Zurich into the frequency of intestinal parasites in man,
and among 994 children examined found only three infants with intestinal
parasites.

According to the statistics of Stiles and Garrison which include statistics
from the United States, the Philippines, India, West and Central Africa,
Italy, England, Russia, and Germany, no entozoa were found in children
under one year.

An intestinal parasite which is very rare in Germany, but relatively
frequent in infants, is Taenm cacumerlna. Its frequency in infants is
explained by its being transmitted by the dog -flea and the close association
so often present between dogs and infants. Taenia cucumerlna in infants
is especially frequent in Denmark, where dogs are very plentiful. Other
tapeworms such as T. flavopiinctata, T. saginata, T. solium and Bothrio-
cephalus are rare in infants, and infestation by Oxyuris vermiculaHs or
Ascaris lumhricoides is not frequent at this age.

Hoflinann, of the Zurich University Children's Clinic, remarks that
much more importance was attached to intestinal parasites, and especially
ascarides, by the older writers than at present, all sorts of symptoms being-
attributed to them, so that it is often diflficult to distinguish truth from
IV. I 2

104 REVIEWS

fiction in the old descriptions. On the other hand, at the present day,
there is a tendency to underestimate the significance of these parasites,
though it is probable that owing to the progress of hygiene the frequency
of these parasites and their complications has to some extent diminished.
In districts where ascarides are extremely prevalent, such as the tropics,
considerable importance is still attributed to them. In European countries
their frequency varies considerably. Thus, whereas, according to Langer,
52 per cent, of the country children in Bohemia are infested with ascarides,
the figures in the towns are considerably lower, e. g. 4 per cent, among the
children in Prague. Hoftmann has collected 63 cases of intestinal obstruc-
tion due to ascarides, including 7 personal cases, 5 of which were in children
aged from If to 9 years and 2 in adults aged 20 and 21.

According to von Uji, who reports a case of intestinal obstruction due
to ascarides, the occurrence and severity of the obstruction do not bear any
relation to the number of the worms. A large number of worms is not by
itself sufficient to cause obstruction, but overeating, errors in diet, chill, and
strain are predisposing causes, von Uji alludes to severe cases of ileus
verininosus collected by Nob^court, of which three were cured by operation,
one died in spite of operation, and three died without operation. The
diagnosis is decidedly difficult, and in most cases the condition is not
discovered until autopsj^ or laparotomy.

According to Crowell, who records his experiences of the parasite in
the autopsy room during several years in Manila, Ascaris lumbricoides
is more widely distributed geographically, and infests a larger number of
persons, than any other known intestinal parasite. Its pathological effects
are classified by Crowell as follows: (1) Mechanical eflfects may be caused
by the worm in the intestine or in the course of its migrations to the bile-
ducts, liver, pancreas, stomach, oesophagus, accessory nasal sinuses, lacrymal
duct, Eustachian tube, external ear, larynx, and trachea ; (2) the worm is
also of importance as a carrier of infection in its migrations to the peritoneum,
liver, gall-bladder, and pancreas ; (3) the larvae cause broncho-pneumonia in
experimental animals, and it is not improbable that they may do so in some
cases in infants ; (4) the presence of a harmful toxic substance is a source
of danger, and reflex nervous symptoms, due either to mechanical or toxic
irritation, are also frequently encountered.

Eberle of Offenbach, states that though over 100 cases of invasion of
the bile-ducts by ascarides have been published, invasion of the pancreas by
these parasites is very rare and usually occurs jjost morteni. Vierordt's
case, published in 1904, was the first in which a definite diagnosis was made
during life, well-marked lesions being found in the pancreas at the autopsy.
Eberle's case, which is the third on record, occurred in a woman aged 45,
from whom 31 ascarides were removed at the operation from the bile-ducts,
and 35 at the autopsy, five hours after death, from the liver, pancreas, and
pancreatic duct, as well as from the oesophagus, stomach, and intestine. She
also presented the very rare association of gall-stones and worms, only
three examples of which have been collected by Neugebauer.

According to Ransom, chief of the Zoological Division of the United
States Bureau of Animal Industry', recent investigations on Ascaris lumbri-
coides have shown that after the young worms hatch in the intestine they
do not immediately settle down, but migrate to the liver, lungs, and other
organs, meanwhile undergoing considerable growth and development.
Those that reach the lungs return to the intestine by way of the trachea

INTESTINAL PARASITES 105

and oesophagus, then settle down and develop to maturity in a suitable
host (man, pig) ; otherwise they are soon eliminated in the faeces (rat, mouse,
guinea-pig, rabbit), or in some liosts undergo an abortive development that
Falls short of fertile maturity.

Hosier, in 1867, and Lutz, in 1868, recorded the occurrence of pulmonary
symptoms in human beings following experimental administration of ascaris
eggs, the symptoms being very probably due to invasion of the lungs by
the migrating ascaiis larvae. Ransom urges that the question of the
occurrence of pulmonary sj'mptoms in human beings as a result of ascaris
infection should receive careful attention, especially in the case of young
children.

Bourges records a case of acquired haemolytic jaundice which occurred
in a young soldier infested Avith Ascaria lumhricoides. The symptoms
gradually disappeared in the course of two months after expulsion of 29
asearides by santonin. All other causes of haemolytic jaundice, such as
syphilis, tuberculosis, and malaria, could be excluded, and there was no
evidence of gastric cancer, cirrhosis of the liver, or myeloid leukaemia.
Bourges therefore concludes that the haemolytic icterus in this case was
due to the action of the asearides on the red corpuscles. He alludes to
a similar case of haemolytic jaundice reported by Darre, which appeared in
the course of ankylostomiasis and was cured after treatment with thymol.

Lawen and Reinhardt examined 620 appendices which had been
removed at St. George's Hospital, Hamburg, since the spring of 1914, and
found oxyurides present in 60 cases, or 9*76 per cent. The worms were
found twice as frequently in the female as in the male appendix. 12 of
the affected appendices occurred in children up to the age of 14, and 48 in
adults. The oldest patients were aged 42, 43, 46, and 62 years, and were
all \vomen. In all but 7 cases, in which the operation showed abdominal
lesions such as tubal pregnancy, cholecystitis, tuberculosis, &e., in addition
to the presence of oxyurides in the appendix, the clinical picture was that of
a mild, moderate, or, in rare cases, a severe attack of appendicitis. The
condition is attributed by Lawen and Reinhardt to the oxyurides penetrating
the mucous membrane and so opening up the path for a bacterial infection.
It is probable also that the toxic action of the parasites causes a superficial
transient inflammation of the mucous membrane. Clinically, a certain
diagnosis cannot be made, but relatively slight objective findings, combined
with fairly acute or chronic symptoms, is suggestive of oxyuris appendicitis.
This diagnosis will be all the more probable if oxyurides have already
been found in the stools several years previously. On opening the abdomen
an abundant serous effusion is sometimes a sign of oxyuris appendicitis,
but frequently the effusion is confined to the serous coat of the appendix.

Furbringer of Berlin, regards the war as mainly responsible for the
unusual prevalence of the Oxyuris vermiculdris lioth among children and
adults within recent years. Whereas, previously', oxyurides were usually
transmitted from children to adults, during the war the young civilian
population had the disease transmitted to them by soldiers home on leave
in whom infestation had been favoured by life in the trenches and barracks.
The change in the character of the food, with the predominance of a vege-
tarian diet, also helped to explain the unusual frequency of oxyuriasis.

Mayer records the results of the examination of the stools or blood, or
both, of coloured prisoners in the prisoners' camp at Wiinsdorf in 1917.
The most striking finding was the prevalence of hookworm infection,

106 REVIEWS

especially among the West Africans (56 per cent.) and the Indians,
particularly the Ghurkhas (62*7 per cent.), in marked contrast with the low-
percentage of hookworm infection among North African prisoners (2-1 per
cent, among 239 examined).

In response to representations made by tlie International Health Com-
mission of the Rockefeller Institute, the Indian Research Fund Association
have devoted a considerable amount of attention to the subject of ankylo-
stomiasis in India. The first inquiry started under their auspices was con-
ducted by Lane among the labour forces employed in the tea gardens in the
Darjeeling districts, 66-02 per cent, of whom were found to be infected with
Necator americamis.

Mhaskar, officer in charge of the ankylostomiasis inquiry in Madras,
reports that the percentage of hookworm infection is nearh^ 100 in the
four districts of Tanjore, Trichinopol}^ Madura, and Ramnad. Of the two
species of hookworm harboured — Necatov ameriranus and Ankylostoma
duodenale — the percentage of the former is nearly 100, while that of the
latter varies widely, being 80 per cent, in Tanjore and 10 per cent, in the
Madura district. Hookworm infection, though universal, was found to var}'
in intensity in the various districts in communities. Freedom from hook-
worm infection appeared to diminish the susceptibihty to bowel complaints.

Megaw, professor of pathology at King George's Medical College,
Lucknow, states that hookwoi'm infection is exceedingly prevalent in the
United Provinces, and that nearly every one there who reaches adult life
harbours hookworms, or has at some time harboured them. Not only does
hookworm infection cause many deaths every year, but it produces some
degree of mental and physical deterioration in an enormous number of
individuals. In the aggregrate there is a very great economic loss to the
provinces.

Caius and Mhaskar have written a series of papers, in connexion with
the hookworm inquiry in the Madras Presidency, on the correlation between
the chemical composition of anthelmintics and their therapeutic values.
Their principal conclusions were as follows : (1) Thymol is a powerful
vermicide acting both on A nhylostoma and Necator. Any dose from 30 to
60 grains in one portion will prove effective. Thymol has mild vermifugal
properties. As its use does not interfere with the daily occupations of the
individual, it is likely to find favour with the masses. (2) 01. chenopodii,
ol. absinthii, ol. tanaceti, and ol. cajuputi are all more or less toxic, and
cannot be recommended as anthelmintics.

Waite and Neilson report that during 1918 the State of Queensland, the
Australian Institute of Tropical Medicine, and the International Health
Board of the Rockefeller Foundation conducted jointly a hookworm inquiry
in North Queensland, and found by stool microscopy 21 per cent, of the
the total population infected. From examination of 340 children, Waite
and Neilson found that hookworm disease produced mental sluggishness
and retarded mental development according to the massiveness of the
infestation. Prolonged hookworm infestation appeared to produce cumu-
lative mental retardation.

Schapiro, state director of the campaign for the relief and control
of hookworm disease in Costa Rica, states that there is a permanent
increase in haemoglobin as the result of treatment, which is also followed
by an increase in earning capacity, and increase in acreage cultivated,
and a marked reduction in morbidity and infantile mortality.

INTESTINAL PARASITES 107

According to Brosius and Bishop, hookworm disease is ahnost universal
among the natives of the district of Zaragoza, Colombia, 98 per cent, of the
inhabitants being affected. All forms of intestinal parasites live and thrive in
the same individual, no type producing conditions inimical to the life of the
others. The writers came to the conclusion that the normal haemoMobin
value of the blood in the natives of this region is somewhat lower than in
temperate zones, viz. al)Out 70 per cent. In the hookworm infested popula-
tion of Zaragoza the average haemoglobin percentage is 47, but an immediate
rise, varying from JiO to 50 per cent., follows expulsion of the worms from
the patient's, intestine.

Darling, professor of hygiene in the Sao Paulo Faculty of Medicine,
describes the work done in the Far East by the Malaya Board on the treat-
ment of hookworm infection. The Board discovered that hookworm
infection existed to a greater extent in the tropical east than was generally
recognized, practically 100 per cent, of the agriculturists, who form the
great bulk of the population, being infected. It was shown that there was
a correspondence between the degree of infection — that is, the actual number
of worms harboured — and the amount of blood loss or anaemia sufiered.
A given number of worms produced more anaemia among children than
among an equal number of women, and more anaemia among women than
among an equal number of men. It was estimated that about 12 hook-
worms were required to cause a loss of 1 per cent, haemoglobin. When the
number of worms harboured was considerable, the anaemia caused was
evident and measurable ; when only a few worms were harboured the
blood loss might not be detectable.

Darling states that the Malaya Board found that chenopodium was
more effective than thymol in killing hookworm, and that it was even more
efficacious in expelling asearis and other helminths such as oxyuris,
trichiurus, and trematodes. The dose of 1-5 c.c. oil of chenopodium was
highly efficient and l)ut slightly toxic, sometimes causing transient dizziness
and vomiting.

Smillie of Sao Paulo, found that large doses of betanaphthol (18 grm.
for adults), which he used in the treatment of 79 cases of hookworm disease,
caused very severe toxic symptoms in two cases and also produced marked
changes in the blood-cells in two other cases. The drug caused considerable
destruction of the red corpuscles, with resultant severe anaemia, icterus,
enlargement of the spleen, liver, and gall-bladder, and haemoglobinuria.
The leucocytes were apparently not destroyed by the drug. Smillie con-
cludes that betanaphthol in large doses is so toxic that it cannot be
recommended for general use in the treatment of hookworm disease.

As the human habitat of the hookworm is the first portion of the
duodenum with extension along the intestine in both directions in the severer
infections, Kantor, gastro-enterologist to U.S. Army General Hospital,
No. 14, has devised an intra-intestinal tube treatment which he claims to be
more efficacious, safer, and, once the duodenal bucket is in place, quicker
than the methods at present in vogue. After introduction of the duodenal
tube, 2-3 c.c. of oil of chenopodium are injected through it, and, after an
interval of six minutes to allow the oil to diffuse through the worm-bearing
area, 2-o oz. of a saturated solution of magnesium sulphate are injected to
prevent toxic absorption of the oil.

Moog and Womer, of the Frankfort University Medical Clinic, allude
to the prevalence of the Tricocephalus trich'iarv.s in soldiers (vide Medical

108 REVIEWS

Science, 1920, 1, 40.2), and report their investigations as to its incidence
among non-combatants. As compared with a frequency of 46 per cent,
among soldiers, the stools of 200 non-combatants showed the ova of Tricho-
cephaliLS trichiurus in 66, or 33 per cent. In none of the cases could any
symptoms be definitely attributed to the presence of worms. The number
of ova in the faeces of the non-combatants was very small compared with
the enormous amount present in the faeces of soldiers. Eosinophilia was
found in only 8 of the 66 parasite carriers and therefore could not be
regarded as a constant symptom.

Mouriquand and Bertoye report an example of a syndrome which is
little known, viz. trichocephaliasis with severe anaemia and diarrhoea.
Such cases may be fatal, but recovery has followed so radical a method as
irrigation of the colon with soap and water through an appendicostomy
opening. This was successful when all else had failed. The present case,
however, proved fatal, and the autopsy revealed myriads of the tricho-
cephalus fixed to the mucous membrane in bunches. No definite haemo-
rrhagic spots were seen. The blood examination showed three million red
cells, but only 20 per cent, of haemoglobin, so that the colour index was
0'3 — a figure seldom met with. There was an eosinophiUa of 11 per cent.

Herzog records a case of bothriocephalus anaemia in which the blood-
picture exactly corresponded to that of pernicious anaemia, although all the
other symptoms of that condition, especially achylia gastrica and glossitis,
were absent. This shows that bothriocephalus anaemia cannot be identified
with Biermer's disease. It is obvious that the bone marrow reacts in the
same manner to different stimuli just as other tissues do. In Herzog's case
there was an extensive pigmentation of the skin which he regarded as
haemochromatosis.

BoTTBGES, H. Syndi'ome d'ictfere hemolytique acquis au eours d'une lombricose.
Kole pathogenique des toxines ascaridiennes dans la genese du processus de
destruction globulaire. Bull, et mem. Soc. mM. d. hop. de Far., 1920, 3^ ser,,
44, 1491-4.

Bbosxus, O. T., and Bishop, W. A. Diseases due to intestinal parasites in
Colombia and their treatment. J. Am. M. Ass., 1920, 74, 1768-78.

Caxus, J. P., and Mhaskab, E. S. The correlation between the chemical
composition of anthelmintics and their therapeutic values in connexion with the
hookworm inquiry in the Madras Presidency. Ind. J. M. Research, 1919-20,
7, 429-63, 570-609, 722-6.

CouziJCATJD, P. Le signe de la langue. Contribution h. I'^tude clinique de
I'ascaridiose et de I'oxyurose. Theses de Paris, 1919-20, 253.

Cboweu:., B. C. The dangers of ascariasis. Am. J. 31. Sc., 1920, 169, 380-98.

DabIiZNO, S. T. Suggestions for the mass treatment of hookworm infection.
Lancet, 1920, ii, 69-72.

Ebeblb, D. Zur Askariden-Einwanderung in die Leber und die Bauchspeichel-
drUse. Schweis. med. Wchnschr., 1920, 50, 1110-12.

FuBBBixrasB. Uber Wurmerkrankungen. Ztschr. f. (irztl. Foi'thUd., 1920,17,
186-93.

HsBzoa, P. Zur Kenntnis der BothriozephalusanSmie. Mi'mchen. med.
Wchnschr., 1920, 67, 1383-5.

INTESTINAL 'PARASITES 109

Hoffmann, W. Askaiidenileus, mit besonderer Beriicksichtigung des Obtura-
tionsileus nebst Mitteilung von 7 Fallen. Monatschr. f. KinderJteilk.. 1919, Orig.
15, 199-231.

Kantob, J. L. The intia-intestinal tube treatment of hookworm infection.
/. Am. 31. Ass., 1920, 73, 1181-3.

liAXTE, C. An investigation into ank5'lostoma infection in 11,000 inhabitants of
the Darjeehng district of India. ImL •/. 31. Research, 1916-17, 4, 274-84.

Law£N, a., u. Beinhabct, a. Ueber das durch Oxyuriasis des Wurmfort-
satzes und Appendicitis ex Oxyurc hervorgerufene Krankheitsbild nnd seine
pathologisch-ariatomischen Grundlagen. 3Iunchen. med. Wchnschr., 1919, 66,
1433-6.

Mateb, M. Uber Stuhl- und Blutuntersuchungen bei farbigen Kriegsgefan-
genen und die Notwendigkeit der AnkylostomabekJimpfung in Britisch-Indien.
Arch./. Schiffs-u. Tropen-Hyg., 1920, 24. 133-9.

McLean, S. Infrequency of intestinal parasites in young children. ./. Am.
3[. Ass., 1920, 74. 1774-5.

Meoaw, J. W. D. Report on hookworm infection in the United Provinces,
Ind. J. 31. Research, 1919 20, 7, 840-63.

Mhaskab, K. S. The prevalence of ankylostomiasis in the Madras Presidency.
Ind. J. M. Research, 1919-20, 7, 412-28.

MoOG, O., u. WoBNEB, H. Ueber Trichocephalus dispar bei Nichtkriegsteil-
nehmern. Berl. Min. Wchnschr., 1920, 57, 109-10.

MoxTBZQUAND, G., et Bebtoye. Trichocephalose a forme chlorotique grave.
Paris med., 1919, ii, 486-8.

Neumann, M. f ber Helminthen bei Siiuglingen. Zfschr.f. Kinderheilk, 1920,
26, 85-93.

Ransom, B. H. A newly recognized cause of pulmonary disease — Ascaris
lumhricoides. J. Am. 31. Ass., 1919, 73, 1210-12.

ScHAPZBO, L. The physical and economic benefits of treatment for hookworm
disease. /. Am. 31. Ass., 1919, 73, 1507-9.

SmzlIiZE, W. G. Betanaphthol poisoning in the treatment of hookworm disease.
/. Am. 31. Ass., 1920, 74, 1503-6.

V. XJjz, S. Ein geheilter Fall von Ileus verminosus. Jahrh.f. KinderheilJc,
1920, 91, 274-7.

Wazte, J. H., and Nezlson, I. L. Effects of hookworm disease on mental
development of North Queensland school children. J. Am. 31. Ass., 1920, 73,
1877-9.

J. D. R.
G. W.

no REVIEWS

DISEASES OP THE SKIN

The most important event in the dermatological worM during the last 1
six months has been the attainment of his seventieth birthday hy the
celebrated physician Unna of Hamburg', and the occasion was appropriately
commemorated by the publication of a special number, on September 8, of the
Dermatologische Wochenschrift, the journal which was founded by him in
collaboration with Hebra and Lassar under the name of Monatehefte fiir
praktische Dermiatologle in 1882, and which has ever since largely been
supported by him and his numerous followers. The special number reveals
his enormous energy and the wonderful variety of aspects under which his
genius has manifested itself.

A contribution to the chemistry of the skin of some importance is
made by Strauss, who has investigated the composition of keratin. He
emplo3^s Unna's method of splitting it by the action of sulphuric acid and
hydrogen peroxide and dissolving as much as possible of the product with
ammonia. The insoluble residue designated Keratin A he finds common to
all varieties of keratin. The soluble portion when acidified yields a pre-
cipitate Keratin B which varies according to the variety of keratin
investigated, e. g. nails, horn, hoofs, hair, &c. Albumoses are also found in
the filtrates. There is no reason to believe that the refractory behaviour of
keratin is in any way proportional to the amount of sulphur contained in it.

Apart from this there has been nothing of striking moment published
on dermatological subjects. Many workers are struggling to solve the still
elusive problems presented by the common diseases of the skin. There
seems to be an increasing tendency to regard psoriasis as an infective
disorder. Bory, for example, defends this theory very strongly, he quotes
several cases where it has apparently been propagated by contagion, and he
also points out that the most successful remedies are parasiticides, associated,
it is true, with reducing agents. Lennhoft' has attempted inoculation
experiments and has inoculated psoriatic subjects with matter from their
own lesions, and in about 15 per cent, of his attempts has been successful.
Control situations inoculated with scales from the author's own healthy
skin did not in any case develop the disease. The majority of people he
regards as immune to the disease, and therefore, he did not attempt to
inoculate them. Adamson. (1) thinks that keratodermia blennorrhagica,
which is always associated with gonorrhoeal arthritis, is merely a form of
psoriasis. He points out that the psoriasis associated with all forms of
arthritis is often of the rupioid type, with scales heaped up into horny cones,
while again in many cases of keratodermia blennorrhagica it is detailed that
the patient had psoriasis on other parts of the body. In some cases it is
diflicult to diagnose between the two conditions. He therefore concludes
that keratodermia blennorrhagica is merely a special form of psoriasis. The
description of a case of this condition by Isaac, in the same number of the
British Journal of Dermatology as Adamson's paper, certainly supports the
latter's theory.

Eczema. In America several observers have been trying to establish
a relationship between eczema and the sensitization of the skin to certain
proteins in the food. Strickler and Goldberg made extracts of proteins

DISEASES OF THE SKIN 111

from many foods and injected patients with them in the hope of getting
reactions in various dermatoses, but their results were indefinite ; so were
those of White, who also found that 28 patients whose eczema was of the
dry variet}^ had an excess of fat in the faeces, while 4 patients with moist
eczema had an excess of starch. Ramirez also tested 78 cases of eczema for
protein sensitiveness with 30 positive results, and 10 of these were cured b}'
removing the faulty protein from the diet. Nevertheless, he concludes that
only a small proportion of eczema cases are anaphylactic. So far this line
of research has not yielded striking results, hut the Americans are still
hopeful. Montgomery and Culver jwint out that there are sevei'al varieties
of eczema of the vermilion border of the lips, some of which are serious and
maj^ become the starting-point of cancer. They strongly recommend
treatment with radium. Galewsky (1) states that many cases of eczema of
the forehead are caused by the leather substitutes in hat linings containing
nitrocellulose and cre.sol. Moro writes on sudden death in eczema; he says
that it always occurs between February and April, and thinks that the
sympathetic nervous system is hypersensitive at this season. He thinks
that the external treatment of infantile eczema may be dangerous if too
successful. The seasonal variations in various skin diseases are also
discussed by Bettmann, but after much deliberation he is only able to arrive
at the conclusion that the totality of cosmo-meteorological conditions aft'ect
the human organism in the most complicated way.

The constant ettbrts made to improve the treatment of chronic sepsis of
the skin are exemplified by Galewsky (2), who writes in praise of ' Sta-
phar ', which is a staph jdococcic vaccine from which poisonous constituents
have been eliminated and which consequently can be given in extremely
large doses. It corresponds to the detoxicated vaccines which are now being
prepared in Great Britain. Montel recommends the local application of
dressings of antistreptococcic serum in cases of erysipelas and lymphangitis,
while Becher advocates the use of a 10 per cent, solution of oil of turpentine
in olive oil in almost all septic conditions of the skin, also in eczema, buboes,
and pruritus. But most observers agree tliat on the whole the collosol
manganese gives as good results as anything in the treatment of obstinate
furunculosis.

The whole subject of lichen and lichenification has been exhaustively
discussed by Dind who upholds the thesis that lichen planus and all its
modifications, together with the lichen simplex chronicus of Vidal or neuro-
dermatitis, are the same disease. His arguments are (1) that the histological
features in all are of the same character ; (2) that both conditions may occur
either simultaneously or in succession in the same patient ; (3) that in eacli
type the course and characters of the eruption point to a parasitic cau.se ;
(4) that both types of lesion are very amenable to treatment with arsenic,
especially intravenous injections of arsenobenzol. It may also be mentioned
that Bonnet and ]\[orenas advocate large doses of cacodylate of soda in the
same conditions. On the other hand Thibierge strongly supports the idea
that lichen planus is quite distinct from lichen simplex and its modifications.
Pigmentation of the skin. With and Kissmeyer have studied the
eftect of Kght baths on patients with vitiligo. They find that at first the
vitiligo becomes more visible, but that subsequently a macular pigmentation
appears on the patches, which may continue spreading after the light baths
have ceased. The vitiligo patches at fii-st react to the light baths with
a stronger erythema than the normal skin, but little by little the patients

112 REVIEWS

are able to stand a quantity of light to which formerly they reacted with
erythema not only upon the normal but also upon the non-pigmented areas
of the skin. Consequently they infer that the organism is capable of
protecting itself against light in other ways besides pigmentation. Vitili-
ginous skin does not give the dopa-reaction, but where the new macules of
pigmentation occur there is an intense dopa-reaction chiefly in the cubical
cells of the basal layer. They regard vitiligo as an exhaustion dermatosis
caused by the using up of the dopa-oxydase by some unknown stimulant.
Their results support the view that all skin pigment is formed in the
epidermis, not in the deeper layers. Wassermann discusses the fact that
the soldier's skin often becomes deeply pigmented, especially in the dark,
races. He thinks that not only exposure but also the food available on
service may contribute towards this. Post-mortem pigmentation of the
skin is dealt with by Neubiirger. He shows that the human skin darkens
after death, especially those parts which are normally inclined to be darker.
The cause of death makes no diflference unless it be Addison's disease or
another condition which augments pigmentation during life. These are
succeeded by increased post-mortem pigmentation. The pigmentation is
independent of bacteria but needs free oxygen. It is derived from the
epidermis and is produced by the oxidation of ' dopa ' or dioxyphenylalanin,
in life carried out by a ferment in the cells of the basal layer. In fact his
results agree with those of With and Kissmeyer.

Tuberculosis. Vogel describes a case of tuberculosis cutis vegetans,
Cranston Low and Logan publish a fatal case of lupus erythematosus in
which tuberculous lesions were found at the autopsy, Kiendl gives a warning
against the use of tuberculin in lupus erythematosus and also states that
the administration of quinine may be followed by a temporary exacerbation
of the eruption, while Adamson (2) writes to point out what excellent
results may be obtained in the treatment of lupus vulgaris by the use of
that old remedy liquid acid nitrate of mercury, both on the skin and also
the mucous membranes, with and without ulceration. His results, which
others have since confirmed, make it appear strange that for so long this
caustic has been allowed to fall into desuetude.

Fungoid infections. Up to recently small-si^ored ringworm was
a rarity in Austria, but it has now been introduced by children returning
from western Europe, where they have been boarded out in order that they
might escape the terrible economic conditions of Austria. Stein, therefore,
has a paper on the differential diagnosis between large- and small-spored
ringworm of the scalp. There is nothing very new in it, but it is interesting
to note that he recommends perhydrol as having more penetrating power
than other drugs. Nathan has studied the production of antibodies in
trichophytic infections. His conclusions are indefinite ; he states that
immunity phenomena occur in these infections and may be demonstrated
sometimes, but not with regularity, not only by cutaneous allergy and
immunity, but also by the presence of antibodies in the blood. Noir^ points
out some of the precautions that must be taken in the X-ray therapy of
ringworm of the scalp, especially the importance of not having the tube too
far away from the scalp. This necessity is often unrecognized.

Herpes zoster. Stern reports the case of a highly neurotic man who
had a recurrent eruption on his right buttock and occasionally on his lips,
also swellings of the glands and an attack of facial paralysis. Probably
a case of herpes febrilis. Bacmeister reports a case where the patient

DISEASES OF THE SKIN 113

apparently infected two other people with herpes zoster by shaking hands
with them. This is intcrcstino-, in view of recent tendency to associate
herpes zoster with varicella.

Urticaria. A case of urticaria tuberosa (Willan) is published by Reiche,
cured l)y atophan. Hoffinann discussed the peculiarities of the urticaria
produced by flea-bites. Ward points out that acute fevers are often
followed by an attack of urticaria.

Scabies. Daul)it advocates the use of soluble sulphur in the form of
the polysulphide of calcium, as being more rapid than the conventional
methods. The danger of dermatitis he thinks can be easily avoided. Pozzo
publishes a case of ' Norwegian scabies ' in a bed-ridden boy afflicted with
tuberculosis from which he subsequently died. Dubreuilli describes an
epidemic of an infective pruriginous eruption occurring among the Ton-
kinese and Annamites imported into France during the war. It was
characterized by papules, like those of prurigo or strophulus, which on
disappearing left a little brown macule. The eruption was mostly upon
the lower part of the body and in the lumbar region. It was certainly
not scabies. Glandular enlargement was common ; no parasites were
found. In hospital a cure was rapidly eflfected by a weak tar and sulphur
ointment.

O'Donovan (1) records an interesting outbreak of dermatitis due to
handling figs infected with a mite which was identified with Carpoglyphvs
2)assularum, one of the sarcoptidae, but apparently unrecognized previously
in this country as a cause of dermatitis.

Scleroderma. A long paper is produced by Adrian and Roederer on
aftections of the joints in scleroderma, with full consideration of the literature
of the subject. The cases are divided into three groups : (1) in which the
atfection of the joints is primary and succeeded by scleroderma ; (2) in
which joints and skin are attacked simultaneously ; (3) in which the skin is
attacked first and subsequently the disease extends to the joints. Cases
are almost all in females. There is a close connexion between scleroderma
and polyarticular chronic rheumatism and certain anomalous forms of
tubercle. The aetiology is completely obscure and no useful therapeutics
are known. Nevertheless, in many cases the prognosis is fair. Izar
publishes a case of generalized scleroderma so extensive as to threaten the
life of the patient, a little girl aged 7, which was completely cured by
injections of hypophysin and pituitrin given on alternate days.

Erythromelalgia. Kunstmann describes a case of this disease which,
owing to obstinate ulceration, had to submit to amputation of a leg, in which
no pathological alteration, either of the blood-vessels or nerves, could be
found. On the other hand, a patient of Chatellier was more fortunate, for
she was cured of the same disease by a single injection of a quarter of
a milligramme of adrenalin.

Fellag^ra. Probizer discusses the astonishing fact that during the war
pellagra almost disappeared from the Trentino. This shows that it is not
caused by misery, want, or psychic disturbances, nor by the Slmuliuin. The
true cause of the freedom from pellagra was the high cost and difficulty of
getting maize. He points out that now that the war is ended it is necessary
to enforce the various laws against the sale of diseased maize.

Alopecia areata. Sabouraud now supports in an ingenious paper,
perhaps somewhat tentatively, the theory that this disease is an abortive
form of congenital syphilis.

114 REVIEWS

Myiasis. A case of ' creeping disease ' occurring in Paris and cured by-
excision is reported by Darier (1).

New growths. Quite a number of papers have been written on these.

Darier (2) records an interesting case of the precancerous dermatosis of
Bowen in an old man in whom almost all the skin of the face was affected.
The disease ran a rapid course and was quite uninfluenced by X-rays.

Savatard (1) (2) (3) has three communications, one a very interesting
one on the earlj^ diagnosis of epithelioma of the skin, which is often missed
in its initial stages. He also publishes a case of leiomyoma or multiple
tumours composed of smooth muscle-cells derived from the arrectores pili
and a case of the rare fibroma simplex. Lenormant describes a case of the
extraordinary condition known as cutex verticis gyrata in which almost the
whole scalp was transformed into a thick, fatty and malodorous cap lined
with deep furrows. It was greatly improved by operation, and reduced to
such dimensions that it could be effectually concealed by a wig.

Darier and Halle publish an interesting case of a naevus derived from
the branchial clefts, containing crypts lined with cylindrical epithelium,
which the authors regard as intradermic branchial fistulae, and Audry
records the case of a child who presented two tumours of the scalp
which contained brain tissue although shut off" from the cerebral contents
by the closure of the cranial sutures. He calls the condition ' aifevo-
encdphalome '.

Tar cancer is discussed independently by O'Donovan and Kuntzel, who
arrive at very similar conclusions, namely, that the incubation is prolonged,
that the commonest site is the scrotum, that the type of growth produced is
not very malign,ant, being late in involving glands, and with very little, if
any, incHnation to metastasis. Henestenberg records a ease of acanthosis
nigricans with carcinoma of the internal organs and destruction of the left
suprarenal body. Satani records a case of extra-mammary Paget's disease
in the axilla, treated surgically. Civatte and Yigne discuss the treatment
of the sarcoid of Boeck-Darier by intravenous injection of salvarsan.
Although it is amenable to this treatment, they still hold that this sarcoid
is tubercular in origin. Degrais and Bellot recommend that X-ray epithe-
liomata in X-ray workers should be treated with radium. They record
three successful cases. Nanta and Paudru describe a case of lymphadenoma
associated with severe pruritus, and finally Merk has a fanciful paper in
which he ascribes Recklinghausen's disease, adenoma sebaceum, and tuberous
sclerosis to infection with some dicotyledonous plant, the ghost of the
structure of which he is able to make out in serial sections !

Cryotherapy. Lortat-Jacob is not satisfied with the conventional
methods of applying carbon dioxide snow to the skin^ and advocates the
employment of a ' cryocautery ', i. e. a vessel tipped with copper, in which
the snow is formed into a solid freezing mass with acetone. He claims the
advantage of more accurate apposition and more intense freezing effect.

Ravaut and Gallerand advocate the treatment of leukoplacia by carbon
dioxide snow ; they cured a case thereby. But it is painful when applied to
the tongue, although on the buccal mucous membrane it is excellent.

Electrotherapy. Tomkinson recommends screened doses of X-rays in
the treatment of Oriental sore, and thinks that the unsatisfactory results
sometimes obtained in this disease may be due to the use of unfiltered rays.
Eitner recommends for the electrolysis treatment of hypertrichosis the
very fine wires used to preserve the lumen of hypodermic needles instead of

DISEASES OF THE SKIN 11.5

ordinary steel needles, which nowadays are ditiieult to get of sutlicient
fineness.

Adamson, H. G. (1). Keratodermia blennorrhagica : is it a form of psoriasis?
nrit. J. Dernmf. 4- Syph., 1920, 32, 183-7.

Adamsoit, H. G. (2). On the treatment of lupus vulgaris by the liquid acid
nitrate of mercury. Brit. M. J., 1920, ii, 123-4.

AdriaKi C, et ROEDEBES, J. Les arthropathies au cours de la sclerodermie.
Ann. de dermat. ct si/ph., 1920, 6e ser., 1, 299-319, 341-59, 395-424.

Audry, C. Naevo-encephalome. Ann. de dermat. et sypli., 1920, 6« ser., 1,

.■;(;9-74.

BacmeiaTSR, a. Die Ansteckungsfidiigkeit des Herpes Zoster. Miinchen.med.
Wchnschr., 1920. 67, 721.

Becher, H. t'ber TerpentinOlbehandlung (Klingmiiller) mit besonderer Beriick-
sichtigung ihrer Anwendung in Dermatologie. Dermat. Wclmschr., 1920, 71,
459-09, 481-6.

Behm, K. Formaliniither bei Intertrigo und anderen Hautkrankheiten des
Kiudesalters. 31iinchcn. med. Wchnschr., 1920, 67, 1173-4.

Bettmann. Ueber jahreszeitliche Schwankungen von Hautkrankheiten.
Miinchen. med. Wchnschr., 1920, 67, 656-7.

BoDiN, E. Note sur quatre cas d'acrodermatite suppurative continue d'Hallo-
peau. Ann. de dermat. et syph., 1920, 6^ ser., 1, 193-8.

BoiTNET, L. M., et MORENAS. Les hautes doses de cacodylate de sonde dans
le traitement do I'eczema et quelques prurigos. Lyon med., 1920, 129, 771-4.

EoRT, M. L. A propos de letiologie de psoriasis. Progres med., 1920, 3® ser.,
35, 281-5.

CHATEZ.LIER, L. Erythromelalgie adrenaline. Ann. de dermat. et syph., 1^20,
6e ser., 1, 261-4.

CrvATTE, A., et Vzgne, P. A propos du traitement de la sarcoide de Boeck-
Darier. Ann. de dermat. et syph., 1920, 6'^ sen, 1, 254-60.

Cranston Low, R., Logan, W. B., and Rutherford, A. A fatal case of
lupus erythematosus, with autopsy. Brit. J. Dermat. ^- Syph., 1920, 32,
253-62.

Darier, J. (1). Cas de Creeping Disease [Larva migrans) contracte ii Paris.
Ann. de dermat. et syph., 1920, 6® ser., 1, 113-20.

Darzeb, J. (2). Le cancer de la dermatose precancei'euse de Bowen. Ann. de
dermat. ct syph., 1920, 6^ ser., 1, 49-61.

Darier, J., et Hai.le, J. Branchiomes cutanes benins. Ann. de dermat. ct
syph., 1920, 6e ser., 1, 1-12.

Daubzt. Traitement pratique et rapide de la gale par la methode d'Ehlers-
Milian. Arch. med. beiges, 1920, 73, 393-7.

Degrais, p., et BeiJiOT, A. Curietherapie des radiodermites epithelioma-
teuses professionnelles. Presse med., 1920, 28, 364-5.

DzND, M. Essais sur les lichens et la lichenification. Ann. de dermat. et syph.,
1920, 6e ser., 1, 273-98, 321-40.

DUBREUZLH, W. Prurigo epidemique chez les Asiatiques importes pendant
la guerre. Ann. de dermat. et syph., 1920, 6® ser., I, 13-16.

116 REVIEWS

EzTNEB, E. Zur Hypertrichosis-Behandlung. 3Ied. Klin., 1920, 16, 361.

GaIiEWSXY, E. (1). Ijber das Stirnekzem infolge Hutlederei-satz und seine|
Ursache. Dcrmat. WcJmschr., 1920, 70, 353-4.

GaIiEWSXY, E. (2). tJber die Behandlung von Pyodermien und alinlichen Affek-
tionen mit 'Staphar' (Maststaphylokokkeneinheitsvakzine nach Strubell). Dermat
WcJinscJir., 1920, 71, 599-602.

Heitestenbebg, W. Ein Fall von Acanthosis nigricans mit Carcinose innerer
Organe. 3Ie(l Klin., 1920, 16, 785-6. " ^

HoFFMAinr, E. Ueber Flohstiche und die Urticaria pulicosa. Deutsche med.
irc/msc/ir., 1920, 46, 1025-6. -^

Isaac, C. L. Case of keratodermia blennorrhagica in a woman. Brit. J. Dermat.
4- Sypli., 1920, 32, 195-6.

IzAB, G. Ii)ofisi e sclerodermia. Riforma med.. 1920, 36, 482-6.

Eabgeb, p. Beobachtungen an Kindern mit trockener Ilaut. Deutsche med.
Wchnschr., 1920, 46, 827-8.

EzENDi., W. Zur Behandlung des Lupus erythematodes. Dermat. Wchnschr.,
1920, 70, 322-8. m

EissMETEB, A. Studies on pigment with the Dopa-reaction, especially in cases
of vitiligo. Brit. J. Dermat. J- %;/i., 1920, 32, 156-62.

Ebeibich, C. Epithelschlacken. Dermat. Wchnschr., 1920, 70, 225-7.

KuNSTMANW. Zur Frage der Erythromelalgie. Dermat. Wchnschr., 1920, 71,
745-51.

KuKTTZEii, O. Uber Paraffinkrebs. Dermat. Wchnschr., 1920, 71, 499-511,
525-31.

Lennhoff, C. Inokulationsversuche bei Psoriasis. Berl. klin. Wchnschr., 1920,
57, 782-3.

Leitobmant, C. La pachydermie vorticellee du lion chevelu. Ann de dermat,
et si/ph., 1920, 6e ser., 1, 225-43.

LoBTAT, Jacob. La cryotherapie en dermatologie. Progres med., 1920, 3® s6r.,
35, 303-6.

Malhebbe, H. Contagion conjugale de I'epidermophyton inguinal. Ann. de
dermat. et syph., 1920, 6^ ser., 1, 205-7.

Mebe, L. Das Wesen der Recklingshausenschen Neurofibromatose, des Ade-
noma sebaceum und der tuberosen Sklerose. Med. Klin., 1920, 16, 808-12.

MoNTEZ., L. H. Traitement les lesions cutanees d'origine streptococcique par
le serum antistreptococcique en badigeonnages in loco. J. de med. de Bordeaux,
1920, 91, 319-2L

MONTOOMEBY, D. W., and Cxjz.veb, G. D. Eczema of the vermilion border of
the lips. Med. Bee, 1920, 98, 141-3.

MoBO, E. Uebererregbarkeit des vegetativen Nervensystems im Friihjahr und
Ekzemtod. Miinchen. med. Wchnschr., 1920, 67, 657-9.

Naxtta, a. Lymphadenome de la bouche et granulome alveolodentaire. Ann.
de dermat. et syph., 1920, 6e ser., 1, 199-204.

Nanta, a., et Baudbu, L. Sur le prurit decalvant lymphadenique. Ann.
de dermat. et syph., 1920, 6« ser., 1, 145-66.

DISEASES OF THE SKIK H7

Nathan, E. Zur Kenntnis der Immunitatsvorgjinge bei der Triohopliytie de3
Menschen. Dcnnaf. Wchnschr., 1920, 71, 439-48.

Neuburger, K. Ueber postmortale Pigmentbildung der Haut. Miinchen.
mc'l. Wchnsrhr.. 1920, 67, 741-3.

NicoLAO, S. A propos du Pityriasis rubra. A^m. dc dermat. el si/ph., 1920,
(3<^ ser., 1, 265-6.

Noire, H. A. propos de la radiotherapie des teignes pratiquee selon la naethode
de Kienboch-Adamson. Ann. de dermat ct si/pk, 1920, 6^ ser., 1, 360-3,

O'DoNOVAN, W. J. (1). Dermatitis due to Carpoglyphus passularum. Brit. J.
JJu-maf. 4- SijpJi., 1920, 32, 297-8,

O'DoirovAir, "W, J, (2). Epitheliomatous ulceration among tar workei-s. Brit.
J. Dermat. 4" Syph., 1920, 32, 215-28, 245-52.

Fozzo, A. Un caso di ' scabies norvegica '. Moryayni, 1920, 62, Archiv. 114-20.

Probizer, G. Die Pellagra im Trentino nach dem Kriege. Dermat. Wehnschr.,
1920, 71, 751-4.

Ramirez, M. A. Protein sensitization in eczema. Arch. Dermat. 4- Syph.,
1920, 2, 365-7.

Ravaut, p., et GalIiErand. Placard de leucoplasie de la muqueuse buccale
detruit par une seule application de neige carbonique. Ann. de dermat. et syph.,
1920, 6e ser., 1, 161-4,

Keiche, F, Urticaria tuberosa (Willan). Miinchen. med. Wchnschr., 1920, 67,

1044,

Sabouraud, R. Sur 1 etiologie de la pelade. Ann. de dermat. et syph., 1920,
6p ser,, 1, 177-92,

Satani, Y, Case of extra-mammary Paget's disease occurring in tlie axilla,
associated with condylomata acuminata in the external genitalia. Brit. J.
Dermat. 4- Syph., 1920, 32, 117-25.

Savatard, L. (1). The diagnosis of early epithelioma of the skin. Brit. J.
Dermat. cV Syph., 1920, 32, 375-80.

Savatard, L. (2). Leiomyoma. Brit. J. Dermal. 4' ^!/2^h., 1920, 32,
229-32,

Savatard, L. (3). Fibroma simplex. Brit. J. Dermat. 4' Syph., 1920, 32,
126.

ScHREUS, B. T. Die Behandlung der Furunkulose mit Eontgenstrahlen.
Mdnchen. med. Wchnschr., 1920, 67, 1169-70.

Steizt, R. O, Die Differentialdiagnose zwischen Mikrosporie und oberflachlicher
Trichophytie des behaarten Kopfes, Wien. Id in. Wchnschr., 1920, 33, 815-18.

Stern, A. Ueber Eigenthiimlichkeiten des Herpes Zoster (Rezidive, Kombina-
ti<m mit Facialislahmung, Aequivalente). Deutsche med. Wchnschr., 1920, 46,
832.

Stowers, J. H. A case of Delhi boil or sore. Brit. J. Dermat. 4' '^VPh-,
1920, 32, 263-5.

Strauss, E. Die Cheraie der Hornsubstanzen. Dermat. Wchnschr.. 1920, 70,
337-48.

StrickXiER, a., and Goldberg, J. M, Anaphylactic food reactions in derma-
tology. J. Am. M. Ass.., 1916, 66, 249-52,

IV. K

118 REVIEWS

TOMKixrsoK, J. G. X-ray therapy in Oriental sore. Brit. M. J., 1920, ii, 397.

Thibiebge, G. Conception generale du lichen de Wilson. Paris me'd., 1920,
ii, 385-9.

VoOEZ., C. Tuberculosis cutis vegetans. Dermat. WchmcJir., 1920, 71, 559-63.

Wabd, E. The occurrence of urticaria after specific fevers. Brit. M. J.,
1920, ii, 279.

WASSEBMAmr, S. rber auffallende Hautverfiirbungen bei Kriegern. Wien.
med. Wchnschr., 1920, 70, 1691-7, 1739-44.

White, C. J. Two modern methods to be employed in the treatment of
chronic eczema. J. Am. M. Ass., 1918, 68, 81-6.

With, C. Studies on the effect of light on vitiligo. Brit. J. Dermat. ^- Syph.,
1920, 32, 145-55.

H. D.

DISEASES OF THE SPLEEN

In the first number of a new journal, Anales de Farasitologia y
Hematologia, published in Madrid, Asua deals at length with diseases of
the spleen.

The spleen has physiolooical, defensive, and compensatory reactions.
The physiological reactions include («) formation of lymphocytes and large
mononuclears, (b) destruction of red and white cells, and (c) inhibitory
effect on bone-marrow function, shown by the appearance of Howell-Jolly
forms in the blood if the spleen be removed, and by a diminution in the
resistance to salt solutions of red cells subjected to the influence of the
spleen. There are further excitor effects on nitrogen, carbohydrate, and fat
metabolism, and less evident effects on digestion.

Defensive reactions are the formation of macrophages, myeloid meta-
plasia leading to increased output of polymorph phagocytes and also forma-
tion of bactericidal substances. Sarcomatous metaplasia is included as a
defensive reaction, and also the mj^eloid metaplasia seen in some anaemias.

The true compensatory function is that evidenced by splenomegaly in
various endocrine defects.

Asua then passes on to a classification of blood diseases designed to
bring out the position of those in which the spleen is most afiected. In his
first group of anaemias, primary haemopathic anaemias, that due to loss of
blood stands alone. The second group corresponds to the myelophthisic
anaemias of some authors and is styled the group of primarj?- myelopathic
anaemias. It contains the anaemias of multiple myeloma, leukaemia, &c.
The third group, haemomyelotoxic anaemias, includes most of the commoner
varieties. There are first those of exogenous causation, e.g. following
administration of blood poisons or the toxins of acute infective disorders.
Secondly are the endogenous, including anaemias which are merely a part
of the general debility attending chronic disorders either neoplastic or infec-
tive, and thirdly, a group of endocrine disorders. Dependent on splenic

DISEASES OF THE SPLEEN 119

disorder, which is thus elevated to a position of primary aetiologieal impor-
tance, we have Banti's disease and haemolytic icterus, while chlorosis is
included as depending on ovarian abnormality. Pernicious anaemia fills the
tliird group ot" haemomyelotoxic anaemias, those of complex causation.

The polycythaemias are also classified, first, into the compensatory and
the pathological. Compensatory pol^'globuly includes the spurious form seen
in emphysema, and the true (as depending on blood destruction) as seen in
some cases of poisoning by haemolytic drugs. Pathological polyglobuly is
seen in Vaquez's disease and in some cases of tuberculosis, after splenectomy,

&'C.

The remainder of this long paper is devoted by Asua to consideration
of the clinical aspect of diseases of the spleen. He considers that Banti's
disease and haemolytic icterus are joined b}* a series of intermediate cases,
and groups them together as hypersplenic disorders. The contraiy group,
asplenia, does not correspond to any recognized clinical entity, but two
cases are given of which one may have been hydatid of the spleen. Defect
of spleen function might, of course, be recognized by the absence of signs of
its physiological functions already detailed, and it is evident that the
removal of inhibitory influences of the bone-marrow leading to polycyth-
aemia bulks largely in Asua's mind.

This paper is somewhat restricted in scope, and includes no notice of
leukaemia, Gaucher splenomegaly, or other diseases of this group, but Asua
has certainly collected a vast amount of information with regard to the in-
fective and endocrine disorders as affecting spleen function, and this is fully
and lucidly set forth.

Splenic anaemia. Mayo propounds the thesis that splenic anaemia
is a clinical entity, i. e. a syndrome which occurs when the spleen is fibrosed,
no matter what the original cause of the fibrosis may have been. He con-
siders that the spleen destroys an increased number of red cells when it is
fibrotic, and that the marrow fails to make up the loss. A chronic anaemia
results, which can be remedied by removal of the spleen.

Aschenheim considers that splenic anaemia of infancy, the von Jaksch
syndrome, is a definite morbid entity due to an inherent weakness of the
haemopoietic organs. He admits that rickets has a great share in the
disease, but would appear to hold that it could not produce it if the inborn
weakness were not present.

Abscess of the spleen. Cutler reports a case of abscess of the spleen
following otitis media, and gives references to the literature. The case is of
interest, amongst other reasons, because there was very slight leucocytosis
until the abscess burst, when the resulting peritonitis caused a large
increase. This accords with the views of Audain on the significance of
leucocytosis.

Gaucher's disease. Sappington reports a case of Gaucher's disease in
a man of 50 who died from gunshot wounds administered by the police.
There was no history of ill-health, but very little could be ascertained about
the patient's antecedents. At autopsy it was noticed that the liver ' ex-
hibited what looked like a moderate chronic hepatitis ', and the retroperi-
toneal glands were moderate)}' enlarged. The spleen ' was in general soft
. . . but scattered all through it were firm nodules more apparent to the
palpating finger than to the eye ... on section, the firmer areas were not
plainly discernible . . . the general colour was normal '. The spleen was sub-
mitted to Mandlebaum for examination, wdio pronounced it typical of

K 2

120 REVIEWS

Gaucher's disease. Sappington throws out the suggestion that the disease
is perhaps more frequent in Jews. Chemical investigation did not reveal
the presence of lipoids.

In an important paper Mandlebaum and Downey conclude that none
of those pathological or experimental conditions which present a superficial
resemblance toGaucher's disease are realljMdentical or even closely analogous.
Their observations show that the ' Massv ' cells characteristic of Gaucher
splenomegaly are derived from the reticulum, although a possible origin
from endothelium as well is not quite disproved. These cells never contain
anisotropic bodies, myelin substances, or neutral fats, as may occur in dia-
betes with lipoidaemia, il'C. Moreover, these cells are by no means of the
definite oval type usually insisted on. They are to be regarded as reticular
cells suffering a particular ' glassy ' change, and vary in shape and attach-
ments from the normal reticular cell in which changes are just beginning to
the free oval or circular cell, whose uses in bodily economy are probably at
an end.

Mandlebaum and Downey believe that the disease is caused by some
metabolic disturbance, l)ut hazard no suggestion as to what caused the
metabolic disturbance which caused the disease. They give a full biblio-
graphy.

Sarcoma of the spleen. According to Duchemin, who records a fatal
case, primary sarcoma of the spleen is very rare. Only about 24 cases have
been published, of which 11 Avere not discovered until the autopsy. Of 13
treated by splenectomy 4 died as the result of the operation, and of the 9
survivors 4 died of a recurrence, 1 was lost sight of, and 4 made a good re-
covery. In Duchemin's case the disease had a rapid course without char-
acteristic symptoms, being manifested first by moderate enlargement of the
spleen and anaemia, and then by cachexia. A diagnosis of malarial spleen
was made owing to the definite action of quinine. But the improvement
produced was mainly local and not general, whereas in malaria just the
opposite occurs. Duchemin suggests that this discordance in the clinical
sjanptoms may facilitate the diagnosis between a malarial spleen and a
malignant growth.

Tuberculosis of the spleen. According to Giffin (1), who records an
illustrative case in a girl aged 16, so-called primarj^ tuberculosis of the spleen
is not exceedingly rare. It is impossible to say that it is ever strictly pri-
mary, for it is almost always certain that an original focus was formerly
present elsewhere in the body, though no evidence of tuberculosis may be
found at the time of examination. The disease may produce an anaemia of
the haemolytic type, and splenectomy, as in Giflfin's case, may result in com-
plete cure. Secondary tuberculosis of the spleen, which is quite common,
is usually miliary in type and very rarely caseous. GitHn is of opinion that
from the standpoint of diagnosis tuberculous splenitis should be considered
in every case with marked splenomegah', in which the findings are not
clearly those of some other disease.

The spleen in abdominal cancer. According to Richard, who devotes
his Lyons thesis to the subject, the size of the spleen in abdominal cancer
does not appear to have attracted much attention. From a study of the
literature he comes to the following conclusions : (1) In cancer of the
stomach the spleen is atrophied. The exceptional cases in which its size is
increased are due to secondary infection in the ulcerated neoplasm, con-
comitant disease or involvement of the spleen by the cancer. (2) The spleen

DISEASES OF THE SPLEEN 121

is atrophied iu massive cancer of tlie liver, eiilaro;ed in adeuo-carcinoiiia
with cirrhosis, and not affected in secondary carcinoma of the liver. (3)
There is no general rule as regards the size of the spleen in cancer of the
extrahepatic bile-ducts, or in cancer of the pancreas, but the spleen is
usually enlarged in cancer of the head of the pancreas and diminished in
size in cancer of the body and tail of that organ. (4) Cancer of the large
intestine, especially of the sigmoid flexure, is accompanied by atrophy of
the spleen. (5) The spleen is enlarged in new growths of the kidiiey,
but atrophied in those of the uterus. (6) Secondary cancerous growths in
the spleen may occur, but are rare, Richard having found only seven
examples among 214 cases of abdominal cancer.

Various forms of splenomegaly. In an article published on March 31,
1919 entitled ' War Splenomegaly ? ' Luccarelli states that for more than
a year he has met -with, enlargement of the spleen in a considerable
number of soldiers without being able to connect it with any present or
past disease such as malaria, enteric fever, spirochaetosis haemorrhagica, or
trench fever. The following explanations are suggested : (1) a toxic state
of intestinal origin due to the food and the character of the life at the front,
including nervous impressions, emotions, fear, &c. ; (2) an abortive form
of trench fever; (3) the presence of the Spirochaeta ictero-haemorrhagiae
or other unknown organisms or causes.

In an article on the Wassermann reaction and chronic splenomegaly,
Weil records 12 cases of chronic splenomegaly, in seven of which a positive
Wassermann reaction was obtained, although there was no evidence of
syphilis, inherited or acquired. Antisyphilitic treatment had no effect on
the splenomegaly or the Wassermann reaction, but caused an aggravation
of the general condition. The positive reaction could not be regarded as
due to the splenic lesions, as in three of the five negative cases leukaemia
was present. Weil suggests that the positive reaction was due to some
unknown parasite.

Bradford describes an obscure and rare disease of which he had seen
only about three examples. It was characterized by a febrile illness closely
resembling enteric fever and lasting several weeks, during \vhich the spleen
slowly increased in size to that reached in ordinary splenomedullary
leukaemia, from which the cases differed in that after an illness of several
weeks the pyrexia declined and the spleen slowly returned to normal. The
y)lood-exami nation showed a condition similar to that of splenic anaemia,
a diminution of the red cells and a considerable leucopenia. Repeated
examination of the blood and stools failed to reveal any organisms of the
enteric group, and the Widal reaction was uniformly negative.

Tuohy reports an unusual case and is unable to find anything similar
in the literature. The salient features were leucocytosis and splenomegaly.
The leucocytes reached as high as 65,000 before &plenectomy and 240,000
afterwards. The patient w^as a w^oman of 40 and complained when first
seen of acute symptoms referable to perisplenitis. So far there is little in
the case to differentiate it from leukaemia, but the differential count was
remarkable in that there were 99 per cent, of polymorphonuclear leucocytes.
No mention is made of any myelocytes or abnormal cells of the white series,
but there was a mild degree of anaemia with a few nucleated red cells. The
patient w^as lost sight of, but reports showed that her health improved after
operation. Four months later she was re-admitted with influenzal pneu-
monia and died before any investigation could be made.

122 REVIEWS

In a paper entitled ' Persistent eosinophilia with hyperleucocytosis and
splenomegaly ', Giffin (2) describes a case which seems to be unique in
medical literature. It therefore requires detailed notice. A man, aged 31,
presented himself for examination in the year 1913. Then, and at various
later dates, he suffered from symptoms referable to obliterative pericarditis,
e. g. oedema of legs and signs of heart failure, and these should probably be
traced to a prolonged fever terminating in pneumonia from wliich he
suffered eight years previously. At the same time he suffered from a series
of symptoms similar clinically to those of some cases of Hodgkin's disease,
viz. general enlargement of glands, splenomegalj^ pruritus, and eosino-
philia. A lymph gland removed from the axilla showed ' a moderate
inflammatory reaction. The germ centres were intact ; a marked endo-
thelial hyperplasia was present. Eosinophil polynuclears were quite
numerous and a few scattered eosinophilic myelocytes were to be found.'
For a full year the patient remained in very fair condition with the
exception of mild anaemia of the chlorotic type and persistent eosinophil
leucocytosis. Repeated search for all sorts of parasites was negative and it
was decided to perform splenectomy. This was done and the patient
benefited considerably, but the glandular enlargement persisted and the
leucocytosis became enormous, on one occasion 208,000 -svith 83 per cent, of
eosinophils.

Two years after splenectomy pruritus developed and was thenceforth
a source of trouble, and six years after coming under obser\'ation he died of
pneumonia.

The spleen at operation showed Malpighian bodies intact but not
numerous, marked cellular hyperplasia and slight increase in fibrous tissue.
Eosinophils were very numerous but eosinophil myelocj'tes very few. The
bone-marrow at autopsy was hyperplastic and contained great numbers of
eosinophil leucocytes. The erythrogenic function seemed to be almost com-
pletely in abeyance. The liver showed ' cirrhosis of a mild grade ', but no
further details are given. There were also present fibrous pleuritis and
pericarditis and perihepatitis. There had been very marked perisplenitis
at operation.

Giffin states that Stillman reported a similar case in 1912 and refers
to one or two cases of Hodgkin's disease which were in various ways
analogous to his own. He was unable to suggest any diagnosis, but con-
siders that the splenectomy was responsible for the high figure reached by
the white cell count.

Levy-Franckel records two cases of splenomegaly following injection of
neosalvarsan. The patients were a boy aged 13 with lupus, and a soldier
with psoriasis, in both of whom the Wassermann reaction was negative and
there was no evidence of syphilis. Leukaemia and pseudo-leukaemia could
be excluded by examination of the blood, and the subsidence of the spleno-
megaly after cessation of the treatment negatived the diagnosis of primary
tuberculosis or cancer of the spleen. Levy-Franckel therefore concludes
that the splenomegaly was due to the neosalvarsan, although no previous
cases of splenomegaly due to this cause have been recorded.

After preliminary remarks on the difficulties in diagnosis presented by
all cases of splenomegaly, Beckmann points out that in no disease are these
more evident than in haemolytie icterus.

He considers the increased fragility of the erythrocytes as an all-
important diagnostic point, and it occurred to him that where the diagnosis

DISEASES OF THE SPLEEN 123

was still in doubt owing to the absence of increased fragility, this sign might
be produced by provocative methods similar to those used in malaria.

He therefore exposed two patients to the direct rays of the sun, gave
alternate hot and cold douches and massage over the spleen, and finally
a dose of X-raj-s. By these means in two cases he reduced the resistance
of the red cells so that whereas they had formerly resisted haemolysis until
a dilution of 0-34 per cent, saline was reached, they now suffered complete
haemolysis in 0-38 per cent. The diagnosis was thus established.

In two other cases already exhibiting fragility there was no change
under the same provocation. He considers that the fragility of the red
cells is due to substances in the circulation and not to inherent marrow
defect, and discusses at some length published views on this point.

The patient seen by Losio had been under medical care on several
occasions, and the question of malaria was raised at an early date, but no
confirmatory evidence was found. He had been treated by X-rays and
iron and arsenic— each time with but temporary benefit. The Wassermaun
reaction was negative, as was the family history. Clinically the diagnosis
of haemolytic icterus was fully established.

Very free venous anastomosis rendered the operation one of no small
difficulty. Microscopically the spleen showed no very marked changes
beyond congestion and thickening of the trabeculae. Pigment in any form
was but slightly in evidence. The arteries, however, were much thickened,
the intiraa being particularly affected. The patient made a good recovery,
but the fragility of the red cells had not returned to normal when the blood
was last examined.

The family studied by Biffis consisted of four generations ; in the first,
three, in the second, four, and in the third, three were sufferers from
haemolytic splenomegaly of the common familial type. In the fifth genera-
tion were five children, descended from three of the previous generation,
but inheriting the abnormalities of their parents in a partial but recog-
nizable degree. Of these five children there was not in every case oppor-
tunit)^ for a complete examination. The details elicited were as follows :

Palmira, aged 7. Debilitated, headache ; pain in the left side of the
abdomen ; fever ; gastric disorder ; diarrhoea ; numerous small glands ; no
icterus of the conjunctivae ; lungs normal ; apical systolic bruit ; liver and
spleen not palpable ; blood examination refused.

Germana, aged 15, sister of above. No icterus; numerous glands;
infantile appearance ; spleen enlarged ; liver not enlarged ; thorax normal ;
blood examination refused.

Emilio, aged 15, student. Good general condition, but pallor evident ;
numerous small glands ; spleen palpable and hard ; no anaemia, but 3-5 per
cent, of reticulated reds and slight anisocytosis ; resistance normal ; serum
contained urobilin and agglutinated the red cells of his sister.

Anastasia, aged 12, sister of the above. Pallor; epistaxis; icterus of
conjunctivae ; several small glands ; apical systolic bruit ; lungs normal ;
spleen felt to be hard and painless on deep inspiration ; haemoglobin 60 per
cent. ; 4-5 per cent, reticular cells ; fragility normal ; auto-agglutination of
her own red cells present and of those of her brother and of her uncle.

Alessandro, aged 13. Indigestion; pain in left hypochondrium ;
diarrhoea ; pallor ; many small glands ; liver enlarged ; spleen not enlarged ;
trace of icterus ; haemoglobin 8 per cent. ; 3 per cent, of reticular cells ; no
urobilin or bilirubin in serum.

124 REVIEWS

Biffis enters fully into the theoretical considerations to which these
cases give rise.

Keisman records a case of splenogenous thrombopenia in a girl aged 17,
who for several years had suffered from increasing enlargement of the
spleen with marked retardation of physical development. Signs of a haemo-
rrhagic diathesis soon appeared, the first evidence of which was severe
epistaxis, which was followed by haemoptysis and bleeding from the gums.
Rapid recovery followed removal of the spleen. The blood picture before
operation was that of secondary anaemia associated with the haemorrhagic
diathesis and thrombopenia. After splenectomy a definite leucocytosis up
to 14,000 appeared, and the number of blood-platelets within 6 hours of the
operation increased from 45,000 to 224,000. Not only did the haemorrhages
disappear, but an increase in weight and general development took place,
and menstruation which had hitherto been in abeyance appeared.

Splenectomy. According to Kleeblatt, splenectomy is indicated in
isolated miliary tuberculosis of the spleen, in all processes associated with
increased haemolysis, such as haemolytic jaundice, hypertrophic cirrhosis of
the liver, the first and second stages of Banti's disease, and, as a last resort,
in the third stage. In pernicious anaemia the operation has a temporary
success. Splenectomy is contra-indicated in portal thrombosis and in ail
processes caused by primary portal congestion and in polycythaemia.

Bellingham Smith reports the case of a boy who had undergone
splenectomy five years previously and was in good health. The symptoms
at the time of operation had been splenomegaly, leucopenia, and general
debility. The Wassermann test was positive, and the liver was seen to be
cirrhotic at operation. As antisyphilitic treatment had been quite useless,
the excellent result from splenectomy is the more noteworthy. Bellingham
Smith also mentions a case of acholuric jaundice in which the operation
was fatal from the supervention of pneumonia.

McConnell is to be congi-atulated on reporting a fatal case of splen-
ectomy for cirrhosis of the liver, i. e. a failure and one of those cases which
is so often more instructive than a success. The considerations which led
to operation are discussed fully and are eloquent of the ever widening
sphere of the operation of splenectomy.

AscHENHEiBS. Zur Frage der Anaemia sj^lenica infantum. Deutsche med.
Wchnschr., 1920, 46, 323.

AsuA, F. J. Funciones del Bazo — hipersplenia y asplenia. Anal, de ParasHol.
y Hematol, 1919, 1, 31-130.

BscKMAmr, E. tJber atypische Fulle von hamolytischem Ikterus. Beutscfies
Archivf. klin. Med., 1919, 130, 301-14.

Biffis, P. Splenomegalia emolitica famigliale. PolicUn., 1919, 26 {Se^. Prat.),
393-409.

Bbadfobb, J. R. Lumleian lectures on the clinical experiences of a physician
during the campaign in France and Flanders, 1914-19, Lancet, 1920, ii, 535-40.

CUTI.EB, E. C. Abscess of the spleen. J. Am. M. Ass., 1920, 75, 1712-5.

DucHEMiN, B. Sur un cas de sarcome primitif de la rate. Theses de Paris,
1919-20, 149.

GiFFiN, H. Z. (1). Tuberculosis of the spleen. 3Ied. Clin. -A^. America, 1919,
3, 765-71.

DISEASES OF THE SPLEEN 125

GiFPiN, H. Z. (2). Persistent eosiuophilia with liyi>erIeucocytosis unci spleno-
megaly. Am. J. M. Sc, 1919. 158, 618-29.

Eeisman, M. Spleiiogene Thrombopenie (essentielle Tlirombopenie, Frank) ;
hiimorrhagische Diathcse ; Heilung darch Milzexstirpation ; Splenoniegalie
Typus Gaucher ; Bemerkungen zur Milzfunktion. Med. Klin., 1921, 17, 72-4.

Ki.E£Bi.ATT, F. Die Indikationen zur Milzexstirpation be! den Splenomegalien.
3IiincJicn. mcd Wchnscht:, 1919, 66, 1291-2.

Levy-FbancksIi, a. Les splenomegalies post-arsenobenzoliques. Bull. Soc.
cle thenip., 1920, 4^ ser.. 25, 248-51.

Losio, L. Aproposito di un case singolare di ittero emolitico splenomegalico
operato di splenectomia. FoUclin., 1919, 26 {Se^. Med.), 410-24.

LuccABEi.x.1, V. Splenomegalia di guerra? Morgagnl, 1919, Archiv. 61,
94-6.

Manslsbaum, F. S., and Dowztey, H. Tiie histopathology and biology of
Gaucher 's disease (large-cell splenomegaly). Folia Haemaf., 1916, 20, 139-202.

Z^ATO, W. J. Splenic anaemia. Contributions to Medical and Biological Eesearch,
dedicated to Sir W. Osier, 1919, 2, 991-1001.

McCoNNEiJ., A. A. Splenomegaly and jaundice — splenectomy. Practitioner,
1920, 104, 278-89.

RzcHABD, L. Du volume de la rate dans les cancers abdominaux. Theses de
Lyon, 1919-20, 102.

Sappington, S. W. Gaucher's disease. J. Am. M. Ass., 1920, 75, 105-6.

Smith, E. B. Splenectomy for splenomegalic cirrhosis, Proc. Roy. Soc. Mcd.,
1919, 13 (Sect. Child. Dis.), 22-4.

TuOHY, E. L. A case of sjilenomegaly with polymorphonuclear neutrophil
hyperleucocytosis. Am. J. M. Sc, 1920, 160, 18-24.

Weii., p. E. La reaction de Wassermann dans les splenomegalies chroniques.
Bidl ct mi'm. Soc. mi'd. d. hop. de Par., 1919, 3^ ser., 43, 111-5.

G. W.
J. D. R.

BILIARY SURGERY

The number of communications on biliary surgery which continue to
appear show the extent to which operative treatment has developed.
Nevertheless there are no generally accepted criteria between the cases
suitable for medical treatment by purgation and those in which
operative treatment is indicated. It is probable that in the majority
of cases of biliar}' disease medical treatment is continued until chronic
jaundice, sepsis and malignant disease produce complications too far
advanced for successful surgical interference. The drainage of the gall-
bladder has proved unsatisfactory, is generally condemned, and avoided
whenever possible. Excision of the gall-bladder has become the most
frequent operation. When performed on early cases, there may be said to
be no danger of death. C. H. Mayo reported 2,460 cholecystectomies

136 REVIEWS

following cholecystitis in the course of three years with a mortality of
1-8 per cent. ; Maccarty reported the examination, between 1913-1919, of
4,998 gall-bladders removed at the Mayo Clinic, the pathological changes
described being of a relatively early kind. Against this must be set the
experience of city hospitals, admitting cases suffering from acute com-
plications involving the pancreas, liver, peritoneum, heart, &c. An
unsatisfactory feature of these early cholecystectomies is that in a certain
proportion there is a relapse after some months, when it may be found
necessary to establish an anastomosis. Then the premature excision of the
gall-bladder may be a matter of regret.

It is continually repeated that an analogy between the appendix vermi-
formis and the gall-bladder affords a justification for the excision of the
latter. It is needless to point out the diii'erences between the two. Patients
over fifty who have long been under medical treatment for chronic jaundice,
however slight and intermittent, are likely to die after operation owing to
recurrent capillary haemorrhage and degeneration of the myocardium.
Septic complications spread both to the peritoneum and to the hepatic veins.
The longer the biliary disease has lasted the more likely is it that the
pancreas is involved. Also after 40 years in 5 per cent, or more of long-
standing cases lualig-nant disease supervenes^ and in only a very few has it
been possible to remove the new growth.

Auatomy and physiology. The gall-bladder, by its glands, forms
mucus to mix with the bile ; its muscular coat and nerve-supply furnish the
mechanism for its rhythmic contractions, the flow in the ducts being aided
to a certain extent by inspiration. The function of the gall-bladder may
therefore be described as of no great importance, and in the majority of cases
it can be dispensed with. This still leaves open the question whether
in a minority of cases there is full compensation for its loss.

An important anatomical point is the junction between the hepatic
and cystic ducts to form the common bile-duct. Whilst the length of
the pancreatic and retroduodenal segments of the common bile-duct are
anatomically constant there is variation as to its origin and in the length of
the supraduodenal segment. Pallin has traced these variations to the end
of the second or commencement of the third month of foetal life. The
typical junction is constituted by the secondary hepatic ducts joining into
one hepatic duct which is about 2-5 cm. in length. This unites with the
cystic duct at an acute angle. But the hepatic duct may be prolonged and
the cystic duct run parallel with it before uniting, so that there may be
hardly any supraduodenal segment of the common bile-duct. The hepatic
duct may then have a length of 5 cm. The cystic duct may not run
parallel but have a spiral course so that its junction with the hepatic duct
is in front.

The cystic artery arising from the hepatic passes behind the hepatic
duct to approach the cystic duct from above and behind.

The ligature of the cystic duct at its termination without infringing
on the common duct and without leaving a segment of the cystic duct
behind as a blind pouch, also the separate ligature of the cystic artery to
prevent recurrent haemorrhage, cannot be carried out with certainty when
excising the gall-bladder, unless this junction of the ducts is first exposed
to view, e.g. by the method recommended by Behrend, noted below.

Those animals which have no gall-bladder have developed in the wall
of the common bile-duct muscular tissue, also elastic fibres which enables

BILIARY SURGERY 127

the duct to dilate and contract, wliilst the discharge of bile is regulated by
the sphincter at the papilla. Hence, in order to compensate in man for the
loss of the gall-bladder, the common bile-duct must be able to act as in
animals, and the function of the sphincter papillae must be unimpaired.

Pathology. Gall-stones are so often found in the gall-bladder in tlie
course of post-mortem examinations that theii- presence is, by many
physicians, still held to be of hardly any importance. On the other hand,
it is widely held that, however slight, gall-stones always show their presence.
If all cases, however vague the symptoms, were submitted to X-ray
examination, it might be possible to demonstrate the presence of calculi
otlierwise undiscoverable.

It is dithcult, before the operation, to say whether the biliary trouble
has arisen by infection through (n) the hepatic artery ; (h) the portal vein ;
(c) through the duodenum and common bile-duct ; (d) through the lymphatics,
or(e) by direct contiguity. In particular, as regards typhoid fever, typhoid
bacilli are said to be always present in the bile of the gall-bladder, but
cholecystitis as a complication of typhoid fever is ipiite exceptional. During
the war paratyphoid was occasionally complicated by cholecystitis, but this
did not require operative treatment.

In Deaver's case acute infective cholecystitis occurred in a girl, aged 5,
after typhoid fever, but she was already convalescent. No typhoid bacilli
were found in the pus mixed with blood contained in the gall-bladder, nor
was the typhoid reaction obtained from the bile. The bladder was incised
and drained, the resulting fistula requiring later to be closed by operation.

Gall-stones are supposed, in the absence of inflammation, to be formed
by concentration and stagnation of Ijile, leading to the deposit of cholesterin
in laminae. Hesse, basing his statements on the observation of 17,402
post-mortems in St. Petersburg, found gall-stones in 0-73 per cent, of men
and 4-75 per cent, of women, gall-stones being comparatively rare in Russia.
Others have found gall-stones in as many as 10 per cent. In 84 per cent,
of the cases Hesse said there had been no previous signs, the majority
being found between the ages of 50 and 60.

X-rays are being employed with increasing efficiency for the detection
of gall-stones ; when lime has been deposited there is a relative opacity ;
when the stone consists of pure cholesterin, there is a translucency in com-
parison with the shadow of normal bile, suggesting air bubbles. But so far
these have been merely confirmatory observations ; the absence of such in
no way contra-indicates an exploration. As the cause or causes of con-
centration of the bile are obscure, the source of gall-stones remains un-
explained, when no inflammation has preceded their formation. When
animals are infected by micro-organisms experimentally, the organisms
with which the animal has been inoculated are to be found in the bile of
the gall-bladder. Inflammation once set, up, it is easy to explain the for-
mation of gall-stones from epithelial debris containing cholesterin and the
lime salts of the bile-pigment?. But then cholecystitis does not necessarily
lead to the formation of gall-stones.

Once formed, there appears to be no evidence at all that gall-stones are
diminished in size or dissolved in any way.

Biliary obstruction not due to gall-stones. The congenital obliteration
of the bile-ducts affects the extrahepatic portion. In a case described by
Dickson the child at birth appeared healthy ; there was rapidly increasing
jaundice from the second day followed by coma and death witliin three

128 REVIEWS

da^'S of birth. The intrahepatic bile-ducts were dihited by bile, aud there
was a little recent small-celled infiltration and cloudiness of the hepatic
cells, which were packed with pigment, but no biliary cirrhosis. The cystic,
right and left extrahepatic, and the common bile-ducts were impervious
cords. The only other lesion was congestion of the suprarenals with
haemorrhages.

Holmes, in reviewing more than 100 recorded cases, reached the same
conclusion that the obliteration occurred outside the liver. In more than
16 per cent, the common duct only was found obstructed, the cystic and
hepatic ducts being well formed. When such is the case the conditions are
the more favourable for the success of an anastomosis. The particular case
he described died at the age of 15 weeks. All the tissues were markedly
bile-stained ; the liver, a deep purple, showed biliary cirrhosis ; the intra-
hepatic ducts normal, and not dilated ; the gall-bladder a fibrous cord with
two dilatations containing greenish-black mucus. Three extrahepatic
ducts met in a common diverticulum 2-3 mm. in diameter at the junction
of the cystic and hepatic ducts. A fibrous cord without a lumen replaced
the common duct down to the papilla. The pancreatic ducts were normal.
Here also the diverticulum at the junction offered an opportunity for an
anastomosis.

Cyst of the common bile-duct. When the common duct undergoes
a stenosis near its termination, it may become dilated into a cyst, Connell
collected 36 cases in which a cyst had formed as a diverticulum up to the
size of a man's head. It extends behind the peritoneum towards the right
kidney whilst pushing the duodenum forward, and to the left and the trans-
verse colon downward and to the left. The diverticulum takes origin in the
upper and middle third of the common duct, the hepatic, cystic and com-
mencement of the common duct being normal. There is present a cystic
tumour with symptoms of biliary obstruction for which an anastomosis
with the duodenum or jejunum should be done ; both drainage and
extirpation being wrong.

Kinking of the cystic duct may be recognized as following the drainage
of the gall-bladder. The fundus being fixed to the abdominal wall, the
gall-bladder shrinks and drags on the cystic duct, which in its turn may
give rise to a kink at the junction with the hepatic duct. In such a case
the discharge consists of mucus, whilst the symptoms of biliary obstruction
persist in spite of the drainage of the gall-bladder. Schmeiden also
explained some cases as due to a kinking of the cystic duct owing to the
gall-bladder becoming over-distended. The cases exhibited symptoms of
a slow intermittent retention in the gall-bladder attended by some pain
but without jaundice, fever, or severe attacks of colic. The attacks of pain,
are of short duration, they occur when an over-filled gall-bladder contracts
upon a kinked cj'^stic duct. Between the attacks, all symptoms may be
absent. It is impossible to distinguish a kinking from obstruction by
a calculus until an exploration is undertaken. The treatment should be
that of cholecystectomy.

Early cholecystitis. Maccarty's description of the early histological
changes resulting from cholecystitis was drawn from the examination of
4,998 gall-bladders removed, in 96-5 per. cent, of which there were gross
pathological lesions as follows : congestion and oedema of the villi : local
and general lymphoc3''tic infiltration of the mucous membrane : in the villi
fibrotic changes. In the mucous membrane and submucous tissue large

BILIARY SURGERY U'3

spheroidal cells collect filled with a fatty material, and it is this which
g-ives the so-called strawberry-like appearance to the interior of the gall-
Itladder. If papillated. the papillae have a yellow or whitish look.

Beflex gastrospasm. Liiain described a local spasmodic contraction
of the stomach occurring with cholelithiasis, as noted by observing the
passage of a bismuth emulsion under the X-rays. Total gastrospasm is
rarely observed ; an ulcer on the lesser curvature leading to the formation
of an hour-glass contraction gives rise to a circular spasmodic contraction.
A spasmodic conti-action affecting the pyloric end of the stomach may be
noted as of resfular occurrence when there is cholelithiasis. The stomach
otherwise appears normal under the X-rays, but as the emulsion passes, the
pyloric region may show a narrow wavy channel, lighter than the rest of
the stomach, followinrr which some of the emulsion is found to have reached
the duodenum.

Operative procedures. Incisions. The incisions employed for exposing
the region of the gall-bladder vary — some commence, at any rate, with
a vertical incision through the middle line or right rectus. Transverse
incisions are warmly advocated because running parallel to the course of
the nerves to the recti muscles. If the recti are cut across it is essential
that afterwards sutures should be passed so as to unite the sheath both
underneath and superficial to the muscle, in order to prevent hernia. When
there is a great depth of subcutaneous fat, the superficial incision used by
Seelig offers a better opportunity for retraction. Commencing over the
xiphoid cartilage and ending a little to the right of the middle line about
the level of the umbilicus, an incision convex to the right includes skin,
subcutaneous tissue and the external oblique aponeurosis together with the
anterior sheath of the rectus. The semicircular flap being raised the deep
incision can be made vertically or transversely.

Cholecystectomy. It was recommended long ago, both by the Mayo
Itrothers and liy Moynihan, that in performing cholecystectomy a commence-
ment should be made by exposing and dividing the cystic duct, at the same
time that the cystic artery is ligatured. To do this Behrend drew up the liver
and gall-bladder to the right, and the pyloric end of the stomach over to
the left. The edge of the gastro- hepatic omentum is thus rendered tense,
its free border is then incised. The junction of the hepatic and cystic ducts
to form the common duct, the portal vein, the hepatic artery and its cystic
branch can then be identified. Unfortunately a great number of cases have
advanced too far for such a procedure. The structures are obscured by
enlargement of lymphatic glands along the cystic, hepatic and common bile-
ducts, which also become buned in oedematous fibrous tissue. All that can
then be done is to commence separating the fundus of the gall-bladder until
a pedicle is reached, including the cystic duct and arteiy, which are ligatured
Vty transfixion. Care must be taken to leave behind some of the cystic
duct rather than to encroach upon its junction with the common duct.

Cancer of the bile-dnct. Malig-nant disease involving the biliary tract
has been unsuccessfully treated hitherto. Pallin first gave an account of
52 cases of malignant disease involving the bile-ducts which had been pub-
lished in Sweden, including the surgical treatment of some of the cases.
The cases complicated by cancer were about 1-2 per cent, of all cases in
which gall-stones were found. Kehr's German experience was the same,
31 cases of cancer among 2-3,000 cases of biliary disease. Cancer attacks
the bile-ducts between the ages of 40-70, especially in women, one-

130 REVIEWS

third of the cases arise at the papilhi. Cancer of the common
duct, at the junction of the cystic and hepatic ducts, or of the hepatic
ducts, is more common in men. The frequency at the papilla of Vater
is explained by the impossibility of drawing a sharp line as to the
starting-point of the cancer, whether at the termination of the bile-duct or
in the mucous membrane of the pancreatic duct, or of the duodenum.
A particular characteristic of carcinoma at the bile papilla, is a papillated
growth projecting like the end of a finger into the lumen of the duodenum.
The other forms of early cancer of the bile-duct is a tumour the size of
a hazel-nut or walnut, a diffuse scirrhous infiltration constricting the lumen,
or a tubular formation, especially attacking the hepatic ducts. The
microscopic structure is essentially the same, consisting of cylindrical
epithelium separated by various amounts of malignant fibrous formation.
Pallin differs from the accepted view that cancer originates by the
irritation set up by gall-stones. Of the 52 cases, gall-stones were found
only in 13, chiefly in the women and in those over 60 years of age. The
finding of a stone in the middle of a cancer does not appear to him
to be evidence of the causation of the cancer by the stone — ^jaundice is
the clue. Symptoms and death are usually due to the cholaemia rather than
to an extension of the growth. Attacks of fever and pain are exceptional,
and then only when the cancer is at the papilla as a late complication. The
distension, or absence of distension, of the gall-bladder is a sign of a very
dubious character, and even if distended it may not be palpable. When the
cancer involves the hepatic ducts, the gall-bladder should be small ; when at
the junction of the cystic, hepatic and common ducts, it may be distended
with mucus ; when involving the common duct and papilla the gall-bladder
may be distended with bile, yet not palpable. If the gi'owth spreads to
involve the gall-bladder it may shrink. A variable jaundice with a palpable
swelling may be due to chronic pancreatitis. Catarrhal jaundice should
subside within a month and there should be no enlargement of the gall-
bladder. It is more easy to exclude cancer at ages below 40.

As to the palliative treatment, drainage is always bad owing to tlie
loss of bile. Anastomosis is especially indicated, and the relief given depends
on the stage of the disease, but an anastomosis connecting the hepatic
ducts is very difficult to carry out. Among the Swedish cases were 9 ana-
stomoses, of whom 3 survived the operation. 2 cholecyst-jejunostomies,
and a cholecyst-duodenostomy. Thej' survived about 6 months each, 2 being
relatively relieved, and one not freed from jaundice and in l)ed all the while.

Four cases were submitted to excision, 3 of cancer at the papilla, all
of whom died of the operation. One case survived after excision of cancer
at the junction of the ducts followed by a hepatico-duodenostomy. There
w^as relief for 10 months; death occurred 11 months after the excision, when
metastatic growths were found in the liver, but there was no recurrence in
situ. Of 44 cases collected from the literature 23 recovered from the
operation. Of these, one of Korte's cases, an excision of a cancer at the
papilla of Vater exposed through the duodenum, followed by drainage of
the hepatic duct, was free from recurrence 6 years after the operation.
Navarro's similai- case was alive without recurrence more than two years
after the operation. Of the remaining 21, 14 were known to have died of
recurrence, 6 in situ, and 5 of metastatic disease, 2 cases survived the
operation 2^ years.

The indications, therefore, are for excision if practicable, generally for

BILIARY SURGERY 131

anastomosis; failing either of these, the exploratory wound should be closed
without drainage.

Anastomosis. There does not seem to he much ditterence between an
anastomosis with the duodenum, jejunum or stomach. It should depend
upon which procedure is the more ' practicable, care being taken that the
gall-bladder is not drawn upon so as to kink the cystic duct. Mathieu
recommended the anastomosis with the stomach because there would be
lees chance of ascending infection. He had operated on three cases for
symptoms of biliary obstruction, and being unable to find the cause, decided
that the excision of the gall-bladder was not indicated. The three cases
had been relieved of all trouble up to date. Dujarier had done this twice,
in one biliary obstruction recurred after some months. In the discussion
on the above cases Tuffier and Quenu suggested that^ such obscure cases of
biliary obstruction often turned out to be pancreatic in origin.

To unite the hepatic duct to the duodenum C. H. Mayo recommended
that adhesions should be disturbed as little as possible when defining the
open end of the hepatic duct. A triangular flap of peritoneum should be
turned down from the duodenum (or from the prepyloric part of the
stomach). Then a short length of a rubber catheter is taken, and a small
collar made from india-rubber tubing of a size next above that of the
catheter is slipped over each end, and one end is inserted into the hepatic duct,
the other through a slit in the duodenum. Then the peritoneal flap is sewn
dowm and thus the tube is kept in position for a time by the collars.

Behbend, M. An improved technique for the removal of the gall-bladder.
J. Am. 31. Ass., 1920, 75, 222.

CoNNELL, A. A. Cyst of the common bile-duct. Brit. J. Surg., 1920, 7, 520.

Deaveb, H. C. Cholecystitis following typhoid fever. Ann. Surg., 1919, 69,
534.

Dickson, W. E. C. Congenital obliteration of bile-ducts. Proc. Boy. Soc. Med.,
Lmd. (Sect. Disea.se of Children), 1918, 11, 27.

He3SE, E. und M. Zur Frage der Hiiufigkeit von Gallensteinen auf Grund des
Sektionsmaterials (17402 Falle) des stildtischen Obuchoff-Hospitals in St. Peters-
burg. ZcntralU. f Chir., 1920, 47, 108.

Holmes, J. B. Congenital obliteration of the bile-ducts. Johns Hopkins Hosp.
Bej)., 1919, 18, 75.

LuAiw, M. Regionarer Gastrospasmus bei Cholelithiasis. Corr.-Bl. f. schweis.
Aerzte, 1919, 49, 1417.

Maccabty, W. C. Early lesions in the gall-bladder. Am. J. M. Sc, 1920,
159, 646.

Mathieu, P. La cholecystogastrostomie dansle traitenient de certaines crises
douloureusesd'origine biliaire. Bull, et mem. Soc. de chir. dePar., 1920,46, 1200,
1261.

Mato, C. H. .Taundice and its surgical significance. Surg. Gynec. 4" Ohst.,
1920, 30, 545.

NErr, J. M. The surgery of the gaU-bladder and biliary tract. Surg. Gynec.
6,- Ohst., 1919, 20 (Internat. Abst.), 1.

132 REVIEWS

FalIiXN, G. (1) Ueber die Lage der Hepaticus-Cysticus-Konfluenz und den
Verlauf der extraliepatischen Gallenwege. Beitr. s. Idin. Chir., 1920, 121, 68.

FALI.IN, G. (2). Das Carcinom des Ductus hepatico-choledochus und seine
chirurgische Behandlung (52 schwedische Falle). Beitr. s. Uin. Chir., 1920,
121, 84.

Schmieden, V. Ueber die ' Stauungsgallenblase ' ? ZentralU. f. Chir., 1920,
47, 1257.

Seelig, M. G. Cholecystectomy. Surg. Gymc. 4" Obst., 1917, 25, 45.

W. G. S.

CONGENITAL TORTICOLLIS

The pathology of Congenital Torticollis, its causation, the nature oi"
the changes in the sternomastoid muscles, and the indications for treatment,
continue the subject of controversy. Meanwhile, the cases mostly come
under the surgeon long after infancy, so that then the removal of the
contracture of the sternomastoid muscle fails to abolish established secondary
deformities, asymmetry of the face, lateral curvature of the spine.

One of the common statements on the subject is that the muscle is
ruptured during birth, especially when a breech presentation entails traction
on the aftercoming head. Another attributes the condition to intra-uterine
disease, in particular to inherited syphilis. Nerve paralysis, and ischaemic
rigidity produced by the partial cutting off of the blood-supply, have been
proposed as causes.

Sippel has contributed observations on 13 infants born with wry-neck.
He supplies in his cases evidence as to the position of the infant in the
uterus, in order to show that the changes in the sternomastoid muscle are
the result of the head of the foetus being turned to one side, so that the
point of the slioulder of that side is pressed into the neck. This produces
an atrophy and contracture of the muscle, affecting especially its deeper
part, also an atrophy of the overlying platysma. Forcible straightening of
the head during birth causes haemorrhage into an already atrophied,
partially fibrosed and contractured muscle, when the subsequent changes in
the muscle are a combination of the pressure atrophy and of the haemorrhage.
But if there is no strain upon the muscle during birth, the torticollis is solely
attributable to the abnormal pressure upon the muscle towards the end
of intra-uterine life.

An infant born with wry-neck requires active treatment forthwith.
In slighter cases massage and movement of the head, so as to stretch the
shortened muscle suffice. In more marked cases the fibrosed and contractured
portion of the muscle should be excised as soon as the child is about a month
old. The cause of the wry-neck is thus removed and there is left a fine
extensile band. The head is held straight and can be turned freely to the
opposite side ; the temporary flattening of the skull and asymmetry of the
face disappear. In none of the eases referred to below did the child show
any lateral curvature of the spine ; early cure of the wry -neck prevents
its occurrence subsequently.

CONGENITAL TORTICOLLIS 133

A skiagram of a foetus, late in a normal pregnancy, shows it with the
head fully extended on the spine, looking straight forward. It is no longer
to be taught that the head is kept flexed with the chin against the sternum.
In consequence of a scarcity of the amniotic fluid, of a narrow pelvis, of
a contraction of the uterus above the cervix, of a twin pregnancy, the
head ceases to be suspended and to move freely in the fluid. It is held
fixed, turned to one side, with the shoulder pressing into the neck of that
side. The arm of the same side, in particular the elbow, is so fixed as to
hold up the head of the humerus. There is thus produced atrophy l)y
pressure of the sternomastoid muscle and the overlying platysma sometime
after the 5th or 6th month of pregnane}'. This cramping of the foetus
favours a breech or transverse presentation, but as shoAvn in the skiagram
given by Sippel, one side of the head may be forced down into the pelvis
with a bending of the neck to one side, if the scanty amount of fluid allows
the wall of the uterus to press unduly upon the buttocks above the pelvis ;
at the same time the spine becomes acutely flexed.

Case I. A primipara aged 28 had been admitted for haemorrhage at
the end of pregnancy. A skiagram showed the foetus in the left dorso-
anterior transverse position with the head sharply bent to the left upon
the neck, and the head of the left humerus occupying the concavity formed
by the bending of the neck. A skiagram of a more regular transverse
presentation, reproduced for comparison, shows the foetus as if lying on its
back with its head on a pillow, directed straight forward.

The woman was delivered by caesarean section, when the position of
the foetus was found to be as above noted. The amount of amniotic fluid
was small. A small female child was seized by the feet and removed without
any strain on its neck.

Otherwise normal, the child showed a marked wry-neck on the left
side ; the face on the left side was flattened, it squinted with the left eye, the
skull over the region of the temporal bone of that side was depressed, the
auricle was flattened and its lobule pushed up. The chin and mouth were
turned over to the right. The left shoulder had been pressed into the neck
below the ear and mastoid process, the arm had been elevated at the shoulder,
and the forearm sharply flexed at the elbow. The left sternomastoid muscle
was so shortened that when the head was turned straight, it was rendered
tense, as seen in the photographs in the article. On being released, the head
returned at once to the position characteristic of left torticollis. The muscle
felt as if strongly contracted, and harder than its opposite. The right upper
extremity had been freely extended by the side, with the shoulder low.
A skiagram showed that there was no spinal curvature, but the left clavicle
as compared with the right had an exaggerated S-shaped curve.

The infant was treated for three months by massage and turning of
the head. Meanwhile the asymmetry of the face, the depression of the
temporal bone and the deformation of the clavicle tended to disappear, but
there was no stretching of the shortened muscle.

Therefore, at the end of three months, an incision was made over the
left sternomastoid which was found shortened, pale, and atrophied. There
was no marked fibrosis ; the blood-vessels and surrounding structures showed
nothing abnormal. A sejrment was removed from the muscle and the head
fixed in a corrected position. A microscopic examination exhibited atrophy
of the muscle, some of the fibres showing degeneration into a homogeneous
substance with loss of both longitudinal and transverse .striations. The

IV. L

134 REVIEWS

degenerated fibres stained badly ; the muscle fasciculi were small and thin,
without any marked fibrosis. There had been no rupture of muscle, and
there was no blood-pigment in evidence of any previous extravasation of
blood.

Case II. A primipara aged 23 was admitted in. labour after premature
rupture of the membranes and the escape of a very little fluid. A skiagram
showed the foetus presenting by the breech with the head bent sharply
to the left upon the neck, and the left shoulder raised and pressed
into the concavity of the neck. The child was born spontaneously up to
the head, which was ' delivered easily without traction or pressure in
a typical way following Veit-Smellie ', and without any anaesthetic being
required. The male child presented a characteristic left wry-neck with the
same features as in the previous case, asymmetry of the face, depression
of the skull, pushing up of the auricle, displacement of the chin to the
opposite side. There was a deep hollow on the left side of the neck
with the surface blue by extravasation of blood into the folds of skin and
into the muscle underneath. The muscle appeared shortened and thinner
than normal. The child died a few days later of pneumonia. The platysma
on the. left side was found very thin, the left sternomastoid muscle markedly
atrophied and intimately adherent to the platysma, the blood-vessels were less
developed than on the right side, there was no thrombosis in the thin walled
veins. There was a recent extravasation of blood into the upper third of the
muscle, which also extended between the superficial and middle layers of the
deep cervical fascia; the deeper part of the muscle had the appearance of
having been contused. The microscopic appearance of a transverse section of
the upper third of the muscle in comparison with that of the right side showed
fewer muscle bundles, the deeper layer of the muscle and the intramuscular
septa were infiltrated by blood and the muscle fibrils largely destroyed.

Case III. A primipara aged 33 with a breech presentation, after
several attempts, was finally delivered, the buttocks by the aid of hooks,
the aftercoming head by forceps. A markedly asphyxiated female child
presented a typical right-sided wry-neck, with suffusion of blood over the
middle and upper third of the muscle, also the other conditions noted in
the foregoing cases. It lived 24 hours. On examination the right sterno-
mastoid appeared markedly atrophied as compared with the left, both its
clavicular and sternal portions; it had been reduced to the size of a lead
pencil ; the platysma was also very thin. There was fresh blood in the
upper and middle third of the muscle against which the right shoulder had
been pressed, and the blood had been extravasated into the cervical fascia.
The muscle was markedly shortened, felt dense, but presented no rupture.
The left muscle was well developed, almost the thickness of a finger, of
normal redness and consistency, without sign of venous congestion.

Ckise IV. A woman aged 22 was admitted in labour with her second
child. The skiagi'am showed a left breech presentation with the head
turned to the right and the point of the right shoulder pressed into the
concavity of the neck. Very little fluid escaped ; the female child was born
spontaneously, except for the Veit-Smellie manipulation of the head, in which
no force was used. There was a right-sided wry-neck together with the
conditions previously noted. The child died a few days later of broncho-
pneumonia, when the right sternomastoid was found much shortened ; at the
junction of the middle and upper third in particular the muscle was dense,
pale, atrophied, the platysma being also atrophied, whereas the muscle on

CONGENITAL TORTICOLLIS 135

the left side was well developed. A transverse section of the muscle showed
changes affecting especially the deeper part ; passing from the superficial
aspect inwards, without any marked line of demarcation, normal muscle
fibres had begun to be separated by an increased amount of fibrous tissue.
In the centre and deeper part of the muscle there was the marked atrophy
noted above ; also there were signs of haemorrhage as shown by blood-
pigment mixed with newly forming fibrous tissue, and recent infiltration of
blood among atrophied muscle fibres.

Cat<e V. A primipara aged 32 sutfering from albuminuria and threatened
with eclampsia exhibited a left head presentation, very little fiuid had
escaped. She was easily delivered by applying forceps to the head. The
child, a male, showed a right wry-neck with the attendant changes. A second
foetus was then found in a right dorso-posterior transverse position, very
little fluid escaped on rupturing its membranes, it was easily delivered
without question of strain on the neck because the aftercoming head was so
small and the maternal soft parts already stretched. The second child, also
a male, showed a left wry-neck, and it died 24 hours after birth. The
platysma on the left side was atrophied and rendered tense by turning the
liead straight, the sternomastoid muscle being shortened and highly atrophied.
The front part of the muscle as well as the deep cervical fascia in the
anterior triangle of the neck was infiltrated by recent blood, the muscle
where infiltrated appeared as if contused. The microscopic changes were
those of atrophy with recent blood extravasation. The firstborn of the
twins survived, and it was intended to operate upon it for wry-neck when
strong enough.

Case VJ. A woman aged 33, giving birth for the fifth time, was
admitted in the seventh month for haemorrhage and rupture of membranes.
After a tampon, two foetuses were born spontaneously, the first, a small
male, showed no deformity and survived. The second, a large male, had
a left wry-neck and bilateral talipes valgus. It repeated the conditions
noted in Case I. After its death, 30 hours later, the left platysma was
found extremely thin and atrophied ; with the very atrophied and shortened
sternomastoid it formed a tense band when the head was straightened. The
pressure of the raised shoulder had been applied especially to the posterior
part of the upper third of the muscle. The muscle under the microscope
exhibited atrophy without haemorrhage.

The following cases came under observation some time after birth.

Case VII. A primipara aged 23 with a normal pelvis was delivered
spontaneously, the left side of the head presenting ; the child was a female,
the amount of amniotic fluid which escaped was small. Three to four weeks
after birth the mother noticed an increasing tendency to a left-sided wry-
neck. When examined at the age of 7 months there was a marked left
torticollis with asymmetry of the face. On straightening the head the
muscle became tense, and on letting go the head at once returned to the
abnormal position. The muscle felt thinner and more tense than on
the opposite side, but not definitely hardened. After a month of massage
and turning of the head without improvement, the muscle was exposed
between the middle and lower third a'nd a piece cut out. The separation of
the cut ends left a hollow in the posterior triangle. The portion excised
showed atrophy of muscle without sign of haemorrhage. Five months later
the wry-neck had been completely removed, a depression persisting where
the muscle had been divided.

L 2

136 REVIEWS

Case VII f. A woman aged 31 with a normal pelvis had been delivered
at term. A breech presentation had required only the Veit-Smellie method
of delivering the head. The mother first noticed the right-sided wry-neck
three weeks later, and the child, when examined at the age of five weeks,
showed the markedly shortened sternomastoid seen in the photograph
reproduced in the article. No improvement following massage, the middle
third of the muscle was excised at the age of 6 weeks. This was pale and
hard like a fibroma, also the superficial and middle layers of the cervical fascia
around it appeared denser. A transverse section showed normal muscle fibres
towards the outer side, the remainder more or less atrophic and separated
by densely fibrous scar tissue. No remains of blood-pigment were seen.

Four months later there was an extensile band thicker than a lead
pencil in place of the excised muscle, and the wry-neck had been quite
removed.

Case IX. A primipara aged 28 with a normal pelvis had been delivered
without difiiculty of a female child which had presented by the breech.
Three weeks later the mother noticed the right torticollis. Massage and
turning of the head failing, the muscle was exposed when the child was aged
8 weeks. The superficial layers of the muscle showed no changes and were
simply cut across ; the deeper part was throughout the whole length of the
muscle changed into hard cicatricial tissue. This part was cut out whilst
avoiding injury to the spinal accessory nerve. The excised piece showed
a fibrosis with atrophy of muscle most marked in the deeper portion of the
muscle. No blood-pigment was noted. The wry-neck was relieved, an
extensile band remaining.

Case X was very similar to Case IX.

Case XI. A woman of 30, at the end of her third pregnancy, with the
foetus in a right dorso-anterior transverse position, was delivered by turning
and extraction by the feet. The placenta had formed a girdle constricting
the lower segment of the uterus, and there had been little amniotic fluid.
The child had right torticollis with the concomitant conditions ; the right
shoulder had been pushed into the neck, the elbow being fully extended and
rendered stiff, along with temporary paresis of the upper extremity from
compression of the brachial plexus. The contraction of the sternomastoid
was overcome by massage and movement.

Case XII, in which the child presented by the breech was one of right-
sided wry-neck, which was also cured by massage and movement.

Case XIII. A woman aged 32, in her second pregnancy, was delivered
of twin children, the first, a head presentation, spontaneously, the second
a right dorso-anterior transverse presentation by turning. The latter infant
had right torticollis which increased after birth, so that at the age of 6 weeks
the indurated middle third of the muscle was excised. There was found
marked degeneration of muscle fibres with fibrosis affecting mostly the
deeper aspects of the muscle, the surface of the muscle exhibited some
normal fibres.

SxPFEi., P. Der angeborene muskulare Schiefhals. Deutsche Ztsclir. f. Chir.,
1920, 155, 1.

W. G. S.

INTESTINAL EXCLUSION 137

INTESTINAL EXCLUSION

Maisonneuve, in 1844, with the object of avoiding the formation of an
artificial anus in eases of intestinal obstruction, orig-inated the idea of
excluding n portion of the intestine by making a lateral anastomosis.
Senn, in experiments on animals, divided the ileum and implanted the
proximal end into the colon, whilst he closed the distal end. Salzer, as
a result of animal experiments, proposed the exclusion of a portion of gut,
after restoring continuity of the rest of the bowel, by closing the upper end
of the excluded o-ut and suturing the lower end of the excluded intestine so
that it should open upon the surface of the abdominal wall. Trendelenburg,
in the case of a cancer of the caecum in which a fistula had already formed,
after restoring the continuity of the bowel, closed the two ends connected
with the caecum above and below, leaving the faecal fistula to persist in
the middle. Other experiments by Vella, in 188.2, tested the consequence
of stitching both ends of the excluded gut into the abdominal wall, so as to
open upon the surface. Denk descriljed the experience over the operation
in von EiseLsberg's Klinik, commencing in 1901.

In 9 cases the procedure followed Senn's metliod, in 3 that of Salzer.
The results in the foi-mer series were :

Case I. For constriction following appendicitis, the division of the
ileum, implantation of the proximal end into the sigmoid flexure and
closure of the distal end. The patient was quite well 16 years later and
had no difiiculty with his motions.

Case II. For tubei'culosis of the caecum was operated upon in the
same way ; there was temporary relief until death 2^ months after the
operation.

Case III. Similar to the preceding one, the ileum was joined to the
transverse colon. A local abscess was incised six months later and death
occurred from tuberculosis two years after the anastomosis.

Case IV. Also tuberculosis of the caecum ; was first treated like the
foregoing and three months later the excluded bowel, including the diseased
part, was excised and the patient cured.

Case V. A fistula had formed after excision of a piece of the ileum.
The operation was done, but the patient died half an hour later from shock.

Case VI. Had both a faecal and urinary fistula, the one involving the
descending colon, the other the left ureter. In addition to the operation as
before, the fistula into the descending colon was clo.sed and the left kidney
removed. The patient recovered from the operation.

Case VII. Tuberculous adhesions constricted the transverse colon for
wdiich ileo.sigmoidostomy with closure of the distal end of the divided ileum
was first tried. Faeces collected in the occluded gut, for the relief of which
three further operations were done, ending in complete removal of the
intervening: ileum and colon.

Case VIII. A carcinoma of the caecum for which ileosigmoidostomy
was done recovered from the operation, but there was no further rejoort.

Case IX. An anastomosis was first done between the ileum and trans-
verse colon, then l^etween the ileum and rectum with closure of the distal
end of the divided ileum, in order to relieve ulceration of the caecum. The
second operation was fatal from leakage at the line of suture.

138 REVIEWS

Case X. There was a cancer of the caecum which had ah-eady per-
forated externally and also into the bladder. The ileum above and the
transverse colon below were divided, the proximal end of the ileum being
anastomosed with the .distal end of the colon ; the distal end of the ileum
was brought to the surface, the proximal end of the colon closed. Death
followed from leakage at the line of suture.

Case XI. There was ileo-caecal tuberculosis with a faecal fistula. The
operation was similar to the preceding case except that the distal end of the
ileum was also closed, and after eleven months the excluded portion was
excised. The patient died five months later from perforation of a tuberculous
ulcer of the ileum above the anastomosis ; there was also generalized
tuberculosis.

Case XII. For a similar case to the above, first appendicostomy and
ileo-colostomy was performed, leaving a faecal fistula. Next the ileum and
ascending colon were excluded and the four divided ends closed, still leaving
the fistulous opening into the caecum discharging muco-pus. Subsequently,
owing to fiirther tuberculous ulceration and communication, a faecal fistula
was re-established and death followed eleven months later.

Denk added the following collections of cases. Of 68 cases of entero-
anastomosis for tubercle, 6 appeared cured, 6 importantly improved, and 27
deaths followed the operation. The inherent danger following tlie operation
was the distension of intervening coils by faeces and gas, tending to cause
perforation and fatal peritonitis. Of 38 cases of carcinoma submitted to
entero-anastomosis, 13 died after the operation, and 19 within the following
2-8 months, 2 were still alive and suffering 14 and 15 months respectively
after the anastomosis, 1 died 7 years later, the growth proving to be a round-
celled sarcoma of the transverse colon. Of 4 there was no further report
after recovery from the operation. In 18 cases a lateral entero-anastomosis was
done for inflammatory conditions other than tuberculous — constrictions, kinks,
adhesions, and faecal fistulae. 5 died of the operation following pre-existing
intestinal obstruction and peritonitis. Of the survivors only 1 was proved
to be well following an entero-anastomosis for Hirschsprung's disease. 5 in
which the operation had been for obstruction, the result of adhesions, had
intermittent trouble from collections of faeces in the intervening loop. Of
2 cases in which the entero-anastomosis was done for faecal fistula, one under-
went excision and died, in the other the anastomosis failed to cure the fistula.

In contrast with the foregoing, the plan of bringing the two ends of the
excluded gut to the surface, and irrigating through it for a time offers
definite advantages.

Finsterer reported the experience gained in Hochenegg's Klinik in
Vienna. Starting from the experiments by Valla in 1882, of Hochenegg
in 1891, and his own in 1916, Finsterer arrived at the decision that the two
ends of the excluded gut should be fixed so as to open upon the abdominal
wall, pending the excision. In support of this conclusion he added 12 recent
cases. Lateral anastomosis had failed owing to the accumulation of faeces
in the intervening gut. When an end to end anastomosis was made, and the
two ends of the excluded gut dropped back, the excluded gut became distended
with muco-pus ending in fatal perforation. Even if there had previously
been a fistulous opening into this segment of the bowel, this did not prevent
the collection. If the proximal end of the excluded gut were closed and
the distal end brought out to open on the surface, there took place an
accumulation in the proximal end above the original site of constriction,

INTESTINAL EXCLUSION 139

so that perforation occurred in the proximal end. When the proximal
end was kept open and the distal end closed, perforation at the distal end
was inevitable.

Case I. An infantry soldier, aged 23, had an appendix abscess incised.
A faecal fistula followed, so six months later an anastomosis was made
between the ileum and transverse colon, and the excluded ends, after
temporary closure,, were fixed into the abdominal wall, 24 hours later the
two ends were opened and tubes inserted for daily irrigation. After three
months, the patient having much improved meanwhile, the excluded caecum
and ascending colon were excised and the patient discharged well.

Case II. A Bosnian, aged 29, had tuberculosis of the caecum com-
plicated by pulmonary tuioerculosis. The caecum formed a mass the size
of the fist with tuberculous mesenteric glands, and excision was out of the
question. The operation as before, followed by daily irrigation, brought
away pus and prevented further abdominal trouble until death, two months
later, from the pulmonary disease.

Case III. An infantry soldier had a faecal fistula in the ileo-caecal
region with necrosis of the ilium following a gunshot wound. 5-| months
later an attempt to close the fistula and remove the necrosed bone made
things worse. 19 months after the wound a second attempt to close the
fistula likewise failed. 23 months after the original wound the exclusion
operation was done, but previous to this the patient had developed signs of
pyaemia, suppuration extended from the ilium through the sciatic notch into
the thigh, and was also present in the wrist-joint, and pulmonary abscesses
followed, which caused death two months after the exclusion.

Case IV was like Case III, but the exclusion operation was done
earlier, viz. 7 months after the wound. Irrigation reduced the discharge
from the ileo-caecal fistula to a little muco-pus. 14 months after the wound,
the excluded gut was excised, and the fistulous track scraped and drained.
The patient was discharged after two months much improved, the track
of the fistula having become reduced to a small sinus.

Case V. In a man aged 46, carcinoma of the hepatic flexure of the
colon had become complicated by a faecal fistula. The exclusion operation
being done, daily irrigation reduced the suppuration so that 5 weeks later
the excluded gut and the cancer were excised. 22 months later the man was
in full work and free from recurrence.

Case VI. A man aged 50 underwent 7 operations on account of cancer
of the lower end of the sigmoid flexure, (i) October 1917. Left inguinal
colostomy for the relief of acute intestinal obstruction, (ii) December 1917.
The cause being overlooked, an attempt was made to close the colostomy and
acute obstruction recurred, (iii) The wound being re-explored, the ileum
was opened, so that a faecal fistula formed; the bowel emptying, the cancer was
discovered and an additional opening made into the caecum, (iv) February
1918. The cancer of the sigmoid was removed along with the descending
colon, the lower end of the sigmoid was closed and transverse colostomy
instituted, with closure of the fistula in the ileum, (v) May 1918. Again
intestinal obstruction was relieved by separating adhesions between the
ileum and the abdominal wall, (vi) May 1918. Union of the ileum to the
sigmoid, leaving a fistula communicating with the excluded caecum, (vii)
June 1917. A partial removal of the excluded gut was abandoned on
finding extension of the cancer to the lymphatic glands and peritoneum.
Just a year after the first attack acute intestinal obstruction recurred

UO REVIEWS

causing death. Perforation had occurred at the site of the ileo-sigmoid
anastomosis following enlargement of mesenteric glands.

Case VII. A man aged 25 had an appendix abscess incised in February
1917, and a faecal fistula followed. In May 1918 the excluding operation
was done and as a result of the irrigation the fistula soon closed. In
November 1918 the excluded gut, which had become much more mobile, was
easily excised and the man discharged well eight weeks later.

Case VIII was a similar case. The appendix abscess was incised in
January 1918 and a faecal fistula followed. The exclusion operation was
done in October 1918, the excision following irrigation a month later, and
the man discharged well in February 1919.

Case IX had tuberculosis of the caecum, which formed a mass the size
of the fist. After exclusion, followed by irrigation for five weeks, the
caecum perforated into the peritoneum and death followed.

Case X was wounded by a shell in the right loin in September 1918,
and like Cases III and IV had a faecal fistula with necrosis of the ilium,
In June 1919 the exclusion operation was done, when, after irrigation, the
faecal fistula closed, whilst the opened ends of the excluded gut discharged
only a little muco-pus.

Case XI, with tuberculosis of the caecum and pulmonary phthisis,
had exclusion done in July 1918. The patient improved so markedly under
irrio-ation, that in February 1919 excision was done, but he died two days
later with signs of pneumonia.

Case XII. A faecal fistula had followed strangulated right femoral
hernia and persisted for two years. After the exclusion operation there
was improvement, but the fistula continued to discharge a little muco-pus,

Mercade reported the following case. A girl aged 16 had an appendix
abscess incised in December 1915, and in January 1918 she presented
several fistulae in the right iliac fossa by which the whole of the intestinal
contents were discharged. On exploration the end of the ileum was found
dilated and the colon beyond the fistulae reduced to the calibre of the little
finger. An end to end ileo-sigmoidostomy was done, and the ends of the
excluded gut closed, leaving the fistulae open. The following day the
patient passed motions by the rectum for the first time for more than two
years. In the following month, February 1918, the ileo-caecal segment with
the fistulae was cut out, the proximal end of the ascending colon closed, the
distal end of the pelvic colon fixed into the lower end of the incision.
Healing followed, a discharge of mucus only continuing from the open
distal end. In August 1918 the remaining colon was excised and the
patient at the time of the report was in excellent general health, had grown
fatter, had solid motions, and but two a day. If, as recommended by
Finsterer, both ends of the excluded gut had been brouglit out, irrigation
might have rendered the ileo-caecal part of the excision easier, and the rest
of the colon might then have been taken away at the same time.

FxiTSTEBEB, H. Ein weiterer Beitrag zur totalen Darmausschaltung. Deutsche
Ztschr.f. Chir., 1920, 155, 145.

Denk, W. Ueber ausschaltende Operationen am Darm (Von Eiselsberg's Fest-
schrift). Arch.f. Min. Chir., 1918, 110, 131.

Mebcade, S. Ileosigmoidostomie termino-terminale suivie de colectoniie
(rapport de Okenczye). Bull, ct mem, Soc. de cMr. de Par., 1921, 47, 160.

W. G. S.

PHYSIOLOGY OF THE ELEMENTARY NERVOUS SYSTEM 141

THE PHYSIOLOGY OF THE ELEMENTARY NERVOUS

SYSTEM : ITS BEARING UPON SOME MODERN

NEUROLOGICAL PROBLEMS

It has been aptly said that the edifice of the wliole nervous system is
reared upon two neurones, the afferent root cell and the efferent root cell.
These are the pillars of the fundamental reflex arc, upon which all the
other neural arcs are superimposed, even those of the cerebral cortex. It is
with the development of these anatomical and physiological foundations of
the nervous system, in those simple animal forms in which they tirst make
their appearance, that Parker deals in his book on The Elementary Nervous
System. Beginning with the sponges, in which contractile muscle-tissue
develops as an independent effector organ before any nervous elements have
been difterentiated, Parker passes to the coelenterates— hydrozoa, sea
anemones and jelly-fish— in which there is a receptor-effector system con-
sisting of sensory and motor elements with their appropriate receptor and
effector organs. In his concluding chapters, he describes the earliest mani-
festations of centralization in the diffuse nerve-net of these primitive animals,
and the appearance of internuncial nerve-cells placed between sensory and
motor elements.

Not only does he deal with the morphology of this primitive neuro-
muscular mechanism, but also with its modes of response. This physiological
aspect of the question is perhaps of even greater interest and importance to
the neurologist than the purely anatomical. At the present moment there is
a great need for accurate and extensive observation upon the nature of the
reactions characteristic of the elementary nervous system, and this for
reasons which call for some preliminary explanation.

Dissolution of function in disease of the nervous system. Within
the past few years, the systematic investigation of the phenomena of nervous
disease has thrown considerable light upon the functions of this system, and
upon the manner in which disease disorders them. Clinical neurology
in this country has never been satisfied by the mere description and
classification of the symptoms of disease, but has always attempted to in-
terpret these in terms of disordered function, and by their study to throw
light upon the physiology of the nervous system. In this way many notable
advances have been made, as, for example, in our knowledge of the problems
of sensation and of the co-ordination of muscular movement. Nevertheless,
many problems await solution, and probably many more have yet to be
recognized.

It is in respect of certain hypotheses concerning the evolution ot
function in the nervous system, and based upon clinical observations, that
the investigations made and so admirably recounted by Parker promise to
be of the greatest value.

These hypotheses are founded upon a general principle enunciated bj-^
Hughlings Jackson many years ago, to the effect that, for purposes of
investigation, nervous disease might be regarded as a reversal of evolution,
that is, as a dissolution, in which function is ' taken to pieces ' in a definite
fashion ; the highest and most recently acquired activities being earliest and
most severely affected, the lower, more automatic and more deeply organized
activities beins: more resistant. Further, such a dissolution being partial —

142 REVIEWS

when death does not ensue — the symptomatology of nervous disease must
be dual ; there will be a negative or defect symptomatology due to loss of
function in the centre destroyed or inactivated, and a corresponding release
from control and unbalanced activity of subordinate centres which remain
intact. In other words, disease dissects out the functional components of
the activity of the nervous system, and from the study of the lower levels of
evolution remaining, light may be thrown upon the gradual evolution
of function in the nervous system.

Fruitful as this guiding principle has been, there is clearly a danger
that it may be laboured, that it may be applied beyond its capacity in the
endeavour to determine the physiological meaning of symptoms. For
example, the hypothesis makes no provision for qualitative alterations of
function, or perversions of function. To apply it universally means that
we accept defect and release as a complete explanation of all the symptoms
of disordered function that we see in nervous disease. Surely this is an
assumption we have no right to make. Be tliis as it may, the principle is
widely accepted as universally applicable, and certain important corollaries
have followed from this.

The one witli which we are now concerned is that this supposed dissolu-
tion of function unmasks earlier phases in the evolution of nervous activity.
Thus, in their well-known work on peripheral sensation. Head and Rivers
maintain that the ' protopathic ' sensibility remaining at the periphery of
a denervated area of skin, and present throughout this ai-ea at the end of
the first stage of regeneration, represents a primitive form of sensibility ;
disease or injury has dissected normal cutaneous sensibility into two physio-
logical components of widely differing capacity and far removed in phjdo-
genetic origin. Similarly, the reflex activity of the isolated segments of the
divided spinal cord in man have been regarded as representing primitive
motor activities released from higher control and reappearing in tlieir
primitive form (Head and Riddoch). In other words, in protopathic sensibility
and in the ' mass reflex ' of spinal man, we see approximations to the sensori-
motor reactions of a primitive animal. In his recent book. Instinct and
the Unconscious, Rivers has fully expounded this biological aspect of the
subject and has summed it up in the following words : ' All we know of the
protopathic stage is consistent with its being the representative of the sensi-
bility of an animal which possesses only the power of becoming aware of
changes of a crude kind and, according as these changes are pleasant or
unpleasant, of reacting at once by such mass-movements as would take it
nearer to, or remove it from, the source of stimulation'. (Rivers, p. 23.)

How far do the facts of observation, as recorded by Parker, confii-m
this view ? Clearly they should aflTord us a valuable means of assessing the
sigiiificance of the phenomena described by Head and his co-workers, and
further, of deciding whether the Jacksonian principle, upon which their
conclusions are based, can be safely applied to all the phenomena of nervous
disease.

The ' protopathic ' animal. With this end in view, let us briefly
examine the sensori-motor endowment of the hypothetical ' protopathic '
animal. Protopathic sensibility is a high-threshold form of cutaneous
sensibility, responding solely to pain and to extremes of temperature. (Head,
Rivers and Sherren, p. 63.) It carries no power of localizing a spot stimu-
lated ; no power of appreciating intensity of stimulus, for the sensations
perceived are of the ' all-or-none ' kind ; there is no power of determining

PHYSIOLOGY OF THE ELE^[ENTARY NERVOUS SYSTEM 143

the nature of the stimulatin<^ object, beyond the fact that it may convey a
pleasant or unpleasant feelings tone ; sensations radiate widely and are often
erroneously localized at a considerable distance from the spot stimulated. In
short, to use Rivers 's words, protopathic sensibility contains ' elements of
vagueness and confusion quite incompatible with the exact power of
localization. . . . ' (Rivers, p. 30.)

To what type of reaction does this extremely strange and restricted foi"m
of sensibility lead ? Head and Riddoch observed that after division of the
spinal cord, the isolated portion, having emerged from the state of spinal
shock, shows an intense reiiex activity. They discerned in this many jxjints
of resemblance to protopathic sensibility. Thus, ' the situation of the stimulus
does not determine the distribution of the response ; local signature is
abolished, and the outburst of energy flows into channels that would be
blocked under normal conditions'. (Head, p. 753.)

The reflex response invariably obtained under these circumstances con-
sists of powerful bilateral flexion of the legs, contraction of tlie abdominal
muscles, evacuation of the bladder, and an outburst of sweating. This is
elicited by all forms of stimulation applied anywhere below the level of the
cord lesion, to skin or to deep structures. The response is stereotyped in
form and unvarying in intensity. Should the stimulus be gentle friction
of tlie glans penis, bladder evacuation is replaced by erection and seminal
emission. This type of 'mass reflex' has been called 'the coitus reflex'.
Apart from this single exception, ' all local adaptation to the site or nature
of the stimulus is swept away in a violent outburst of energy in centres cut
off from higher control'. (Head, p. 753.) And again, 'a reaction of this
kind is admirably fitted to defend the animal from noxious influences ; it
produces movements of withdrawal, which permit of no choice '. (Head,
p. 752.) Finally, and scarcely consistently, ' both the segmental and the
massive response are means of defence and lead to withdrawal of the part
from noxious influences. But they hamper voluntary action by the uncon-
trolled movements they evoke, and tend to prevent escape by fixing the
body in a position unfavourable for flight. The animal crawls into a hole
to die or to recover . . . ' (Head, p. 753.) The ' mass reflex ' is .said to
represent the reappearance ' in its primitive form ' of an elementary motor
mechanism normally kept under control.

It is very difficult to regard this chaos of reflex responses as anything
but a pathological demonstration of what might aptly be called spinal
anarchy. The protopathic animal, in response to a stimulus which it cannot
localize, which has but a single intensity and gives no information as to the
nature of the stimulating object, makes a response which consists of profuse
sweating, bladder evacuation, and powerful tonic flexion of the hind limbs,
or squatting. The primitive animal thus endowed would be an organism
utterly unfitted to cope with its environment. So helpless and bewildered a
creature could not survive long enough to perpetuate its race, even if it could
make an effective effort to do this, and with its appearance the process of
evolution must almost inevitably have ceased.

These reflections are forcibly suggested by the biological consequences
of this theory of the dissolution of function. Let us see what actual obser-
vations upon the physiology of the elementary nervous system have to say
on this point.

The elementary nervous system. In the case of such a primitive

144 REVIEWS

animal form as the jelly-fish, or the sea anemone, we can determine the
presence of graduation and localization of sensation only by a close study of
the characters of the response. In these animals there are several forms of
effector organ, but of these only the muscle is under nervous control. We
must therefore study the motor responses of these animals.

If the sea anemone Metridium be stimulated at any point by a glass
rod, the whole musculature of the animal goes into strong tonic contraction.
If, however, we employ physiological stimuli, finely graded motor reactions
may be observed. ' If a Metridium be allowed to remain for some time in
running sea water in a situation relatively dark, its muscular tonus will be
reduced to a minimum, and it will assume the condition of fullest normal
expansion. If, under such circumstances, it is generally and briefly illumin-
ated, it will quickly shorten its length quite noticeably, though it will by no
means go into what would be described as a state of contraction. This
shortening of the animal as a whole is due to the simultaneous moderate
contraction of its longitudinal mesenteric muscles. The fact that the
shortening is symmetrical and uniform shows that a complete ring of these
muscles has contracted in unison. If, instead of subjecting the fully expanded
sea anemone to a general illumination, light is thrown on only one of its
sides, it responds usually by turning its oral disk toward the light, precisely
as some flowers come to face the light . . . hence the nerve-net exhibits under
a more normal form of stimulation a type of response much more delicate
in character than what is seen when a glass rod is used.' (Parker, p. 100.)
Finally, Parker concludes that the responses of such an animal are not of
the ' all-or-none ' character, but are finely graded according to the strength
and the site of the stimulation.

The response of the tentacles to stimulation show the same features as
those of the musculature of the wall of the organism. (Parker, p. 123.)
Further, according as we stimulate the tentacles of the sea anemone with
either weak acid or with fish meat, so the whole nature and site of the
response differs completely.

Finally, in the tiny polyp Corymorpha, Parker has observed the follow-
ing delicately localized and graded response to localized stimuli (p. 189) :
' If a faradic stimulus is applied to one side of the stalk next the hydranth
or next the base, the stalk simply shortens as a whole. If, however, the
stimulus is applied to one side of the stalk nearer the middle of its length
the stalk bends to that side and usually presses the hydranth with great
accuracy against the stimulated spot. This response is not only appropriate
for the particular side stimulated, but also in most cases for the given level
of the stimulated spot on that side. The significance of these responses to
localized stimulation were often observed in the stock aquarium. This con-
tained by accident a number of small nudibranch gastropods, which were
found to feed upon the substance of Corymorpha. When one attacked
a Corymorpha, it began near the base of the stalk where the hydroid rose
from the mud, and as soon as it started to nibble the stalk on a given side
the Corymorpha responded by applying to the point of attack the hydranth,
the tentacles of which were extremely stimulating to the nudibranch and
usually drove off* the intruder. The success of this fwTifi of protective
response naturally dep)encled upon the accuracy of the localization. . . . This
accurate form of response of a distantly located organ to a circumscribed
stimulus has all the characteristics of a reflex. . . . '

Differentiation and integration. Therefore, it seems that from its earliest

THYSIOLOGY OB^ THE ELEMENTARY NERVOUS SYSTEM 145

origin, the nervous system is capable of assuring- a perfect tbouoh simple
co-ordination. Sherrino-ton lias emphasized that a simple act of co-ordination
may be as perfect as a highl}' complex one, and that, as differentiation of the
organism takes place, the integrative activity of the nervous system keeps
pace with this differentiation. The so-called ' crude ' forms of activity,
which Rivers supposes the elementary nervous system to possess, are
nowhere to be observed throughout the animal kingdom, whether we study
jelly-fish^ insects, or man. Indeed the use of the Avord ' crude ' in this
connexion is greatly to be deprecated. It means almost anything and
therefore defines nothing, and it has no more place in biology than that
quaint figment ' the protopathic animal ', whose nervous system it describes.
The elementary nervous system may be simple and limited in its range of
action, but crude never.

Indeed, it seems clear that in respect of insect behaviour Eivers is con-
scious of some discrepancy 1)etween his hj^pothesis and the observed facts,
and he assumes that the finely discriminated and graded reactions of insects
must have been derived from ' originally crude modes of response' under
the influence of some unknown * graduating mechanism ' (p. 50). We cannot
refrain from asking whether this Avay of looking at things is likely to lead
us any nearer to a solution of these interesting problems. We can find no
reason for these two assumptions, unless it be the requirements of an
hypothesis Avhich is not in accord with the facts. Surely, a more promising
line of advance would be rather to study the reactions of the elementary
nervous 'system and to base our theories on what we observe, than to roll
this academic hypothesis before us, Sisyphus-like, in our efforts to attain
objective truth.

To these principles which Sherrington has emphasized, and to these
facts of observation, the wliole conception of protopathic forms of sensibility
and motor reaction runs directly counter. What is of even greater impor-
tance is that this wide diversity between the hypothesis of Head and his co-
workers in this respect and what we actually know of the elementary
nervous system, shows that the Jacksonian principle is a fallible instrument
if it be employed as a universal law, which Jackson surely never intended,
instead of as a working hypothesis to be used with discrimination. In our
future interpretations of the symptoms of disordered nervous function, we
shall have to take account of the probability that function is sometimes
qualitatively altered or perverted in a fashion not to be explained along
these simple lines.

[The page numbers in the references to the papers of Head and his
collaborators are from the collected Neurological Studies, and not as in the
original papers in BrainJ]

Head, H. Studies in neurology. 2 vols. Oxford Medical Fuhlications, 1920.
Jackson, J. Hughlin'OS. Evolution and dissolution of the nervous system.
Croonian Lectures, Royal College of Physicians, 1884. Brit. 31. J., 1884, i, 591,
660, 703.

Fabkeb, G. H. The elementary nervous system. J. B. Lippincott Co., 1919.

BivEBS, W. H. R. * Instinct and the unconscious '. Cambridge Medical
Series, 1920.

Shsbbxngton', C. S. The integrative action of the nervous system. Con-
stable, London, 1906.

F, M. R. W.

ABSTRACTS

NEUROLOGY

Dbaper, G. Acute poliomyelitis. William He ineman, London, 1917.

The fortunate circumstance that these islands have never been ravaijed
by severe epidemics of acute poliomyelitis has deprived observers in this
country of the extensive opportunities, which the outbreaks of the disease
in the United States have afforded observers there, of studying the acute
initial stages of the disease. There appears to be nothing sufficiently
characteristic of the acute systemic phase of this to render it recognizable
when none but sporadic cases occur.

Although the well-known Rockefeller monograph of 1912 and Batten's
Lundeian lectures of 1916 (Brain, 1916,39, 115) summarized our knowledge
up to the latter date, yet Draper's account contains a more detailed description
of the initial symptomatology of poliomyelitis than has yet been available
in this country, and will therefore be read with interest.

A striking feature revealed by the study of the disease in epidemic
form has been the large proportion of cases which never develop paralysis.
This fact has been known for some years, and has been completely borne
out by the American epidemics of the last five years. Draper places the
proportion of non-paralysed cases at 50 per cent., and quotes other authorities
who place it as high as 70 per cent, and 80 per cent.

It follows from this that the terms ' abortive type ', ' infantile paralysis ',
and ' poliomyelitis ' applied to this disease are not accurate, since the acute
systemic phase of the disease is not necessarily accompanied by any involve-
ment of the nervous system. Further, any classification based upon the
incidence of the paralysis fails to include at least half of all recognized cases.
Since both paralysed and non-paralysed cases show the same initial systemic
symptom-complex, he proposes a basis of classification according to the
characters of this phase of the disease.

The acute or active stage of poliomyelitis consists of two phases : a first
phase of general toxic-infection, which ends either in recovery, or is succeeded
by a second and distinct phase of nervous involvement. It appears that
death in this disease is never due to toxaemia, but to direct involvement of
the nervous mechanisms of respiration. Hence, death never occurs apart
from the development of the second phase.

The first phase — general toxic infection. This is invariably febrile,
and lasts from 24 to 48 hours. It may be followed by a complete remission
and apparent recovery of the patient, but after an interval of from 3 hours
to several days, paralysis suddenly appears and ushers in the second or
nervous phase. On the other hand, no such remission may occur, and the

NEUROLOGY 147

lirst and second phases may be continuous. For these two variations,
Draper lias employed the somewhat fanciful terms ' dromedary type ', from
the occurrence of two ' humps ' of symptoms, and ' straggling type ' respec-
tively.

The symptoms accompanying the fever and constituting the clinical
picture of the S3^stemic phase are not in themselves particularly character-
istic of poliomyelitis. They vary in different epidemics, and in different
foci in a single outbreak. They may be predominantly (a) gastro-intestinal,
when diarrhoea is a prominent symptom ; (b) tonsillar, or (c) upper respira-
tory, or ((/) pains and malaise may be the only definite symptoms noticed.
Whatever form the symptoms take, they vary in intensity from case to case.

In the early hours, the clinical picture resembles that of any other acute
specific fever of childhood. The child is dry, hot, and restless. When
gastro-intestinal symptoms are prominent, the case may be taken for simple
summer diarrhoea. It is important to remember that these symptoms are
not prodromata of the disease, but the manifestation of the fully developed
ireneral infection itself.

Draper states that observers seeing cases during an epidemic soon
learn to appreciate trifling and subtle clinical features, by which they can
often detect the nature of the illness. Other common symptoms are pain
and tenderness of muscles, congestion and soreness of the fauces, and enlarge-
ment of the lymphatic glands. While diarrhoea is common during the first
phase, after nervous involvement has appeared, constipation is the rule.

The phase of nervons involvement. The degree of nervous disturbance
varies from a mild and transient meningeal reaction to widespread paralysis
and death. It is diflScult to determine, from the character and severity of
the symptoms during the first phase, whether paralysis is likely to ensue.
As we have seen, a complete remission of symptoms may intervene between
the first and second phases of the acute disease, but, nevertheless, there are
commonly both clinical and other indications of invasion of the meninges by
the virus before paralyses appear. Among these is the * spine sign '. This
consists in rigidity of the spine, passing sometimes into opisthotonos. Its
appearance, or its sudden increase, during the early hours of the illness is
a relial)le indication that the nervous system is beginning to be invaded.
Other manifestations are sudden and transient changes in the tendon-jerks,
increased muscular pain, and headache. Repeated lumbar punctures during
this period reveal the meningeal reaction which underlies these symptoms.
During tlie early hours, and when no meningeal symptoms are present, the
cerebrospinal fluid is found to be under pressure, but contains no abnormal
increase of cells or of globulin, but with the appearance of meningeal
symptoms, sometimes without these, the fluid shows an increasing cell con-
tent. At first, and in severe cases, numerous cells resembling polymorpho-
nuclears are seen, but later the cells are exclusively lymphocytes. The
content may range from any number over ten per cubic millimetre to over
a thousand. As a matter of practical interest. Draper records that if during
the first 12 to 18 hours the cell count does not exceed 100 per c.mm.
paralysis is not likely to follow.

However, prognosis during the preparalytic period is difficult, since the
nervous symptoms of the second phase may be as trivial and transient as
those of the first.

Clinically, cases passing on to a phase of nervous involvement may be
classified as follows : (1) transient meningeal reaction with recovery ; (2)

148 ABSTRACTS

stupor followed by transient facial paralysis and recovery; (3) transient
limb or trunk paralysis ; (4) persistent paralyses with slow and partial
recovery ; (5) fatal cases in which the nuclei of the intercostal and phrenic
nerves, or the respiratory^ centre in the medulla, are involved. In these the
paralysis may be ascending or otherwise progressive.

While motor nerve-cells in brain-stem or cord are most commonly
involved, it is known that the upper motor neurones may also be attacked,
with the production of true encephalitic types, with hemiplegia and con-
vulsions.

Treatment. In the general management of a case, Draper insists on
isolation not only of the case itself, but, for a period of ten days, of the rest
of the family. The occurrence of cases without ensuing paralysis makes
efficient quarantine in an epidemic impossible, for these cases are the most
active spreaders of the disease. During an outbreak, it should be remembered
that both nasal secretions and faeces are infective, and possible carriers
should be particularly careful to see that their hands are kept as clean as
possible in these respects. During the most recent outbreak of the disease,
the use of serum treatmetit began to come more extensively into use, but it
has not yet been developed on a large scale. Experience, both experimental
and clinical, shows that immune serum from a recovered case is more likely
to protect the nervous system if administered before, or early, in the
meningeal invasion period. Before there is any sign of meningeal in-
vasion, intravenous or subcutaneous injection of serum from a recovered
case is advocated, but once signs of meningeal invasion have appeared,
intratliecal injection is preferable. During an epidemic it should be easy to
obtain the required serum, but for cases occurring sporadically there will
probably always be considerable difficulty in hurriedly obtaining an immune
serum, in excluding syphilis in the donor, and in injecting it before paralysis
has developed — if diagnosis is possible before this — or within a few hours of
its appearance. So that, in the conditions under which poliomyelitis is seen
in this country, serum cannot yet be considered a potent weapon in the
hands of the physician.

If there is any fault to be found with Draper's valuable account, it is
that the wealth of information it contains is unsystematically arranged.
The use of metaphorical terms, such as ' dromedary ' and ' hump ', cannot
replace lucidity of expression, or system in arrangement. Indeed, the
physicians of fifty years ago, who gave us such living and vivid accounts of
the diseases they described, never found it necessary to eke out their
vocabulary by the adoption of far-fetched zoological metaphors of this kind.

F. M. R. W.

Levaditi, C, et Habvier, P. i^tude experimentale de I'encephalite dite
lethargique. [An experimental study of so-called lethargic encephalitis.]

Bull, de I'Inst. Pasteur, 1920, 34, 911.

From their experimental studies, Levaditi and Harvier have arrived at
the following conclusions :

1. That the virus of encephalitis is paithogenic for the rabbit and for
the guinea-pig, but little or not at all for the monkey.

2. The symptomatology and pathology of the experimental form of the
disease closely resembles the disease as seen in man.

3. The causative agent is a filterable, virus, which lives for 48 hours

NEUROLOGY 149

after death of the infected animals, persists in glycerine, but is killed by
prolonged contact with phenol at 100° C.

4. The rabbit can be successfully inoculated through the eye or the
peripheral nerves, but not through the skin, the blood-stream, the peritoneum,
the air-passages, the intestinal canal, or the salivary glands.

5. The intact nasal mucosa resists the invasion of the organism unless
it is inflamed or damaged. In the latter circumstances the virus probably
travels along the olfactory nerve filaments to the brain.

6. The virus is found in the brain and cord, but not in the blood or
cerebrospinal fluid, or in the viscera, including the salivary glands. It is
excreted via the nasal mucosa, which it probably reaches along the olfactory
nerve filaments from the brain.

7. In man, infection probably occurs through the nasopharynx.

8. The experimental disease does not clear up spontaneously, hence
there is no subsequent period of immunity, but a certain degree of artificial
immunity can be conferred by vaccination with live or dead virus.

9. The serum of convalescents and of vaccinated animals has no pro-
tective properties, or bacterial action on the virus.

10. Experiment and minute histology suffice to differentiate this disease
from acute poliomyelitis. Neither of these diseases confers immunity for
the other.

11. Certain cases of acute febrile chorea are due to the virus of
lethargic encephalitis.

12. There are attenuated varieties of the virus, and these can be kept
alive ill vitro in sj^mbiosis with cellular elements. F. M. R. W.

EaIiBERLAH, F. Zur Aetiologie der multiplen Sklerose. [The aetiology of
disseminated sclerosis.] Deutsche med. Wchnsckr., 1921, 47, 102.

Kalberlah inoculated rabbits intradurally and intraperitoneally with
blood and cerebrospinal fluid from two active cases of disseminated sclerosis.
One of the inoculated animals developed paralyses, and from its blood
during life a spirochaetc was obtained. A second animal inoculated from
this also developed paralyses, but its blood revealed no spirochaete.

The rabbit inoculated from the second case died within two weeks and
the expressed liver juices, when stained by Giemsa's method, showed
a spirochaete similar to that found in the first case.

The organism is plumper than S. imllidn, and tapers to a point at each
end. It has from three to six spirals. Neisser and Klein examined
Kalberlah's preparations and confirmed his observations.

Healthy rabbits and animals dying from other causes in the cages did
not show a similar organism.

Kalberlah names it SjJ'rochaete 'poly sclerotica, and considers it to be in
all probability the cause of disseminated sclerosis. F. M. R. W.

Fabkeb, H. L. Juvenile tabes : review of the literature and summary of
seven cases. Arch. Neurol. ^- Psychiat., 1921, 5, 121.

In a review of the literature, Parker finds that tabes is the rarest form of
syphilis of the nervous system in children. Meningovascular syphilis and
general paralysis are both more common. On the whole, girls seem to be
more frequently affected than boys ; in this respect the juvenile form is in

IV. M

150 ABSTRACTS

striking contrast to the adult form. The average time of onset is the period
of puberty. The parents usually show a positive Wasserraann reaction, and
the frequency with which the parents of juvenile tabetics are themselves
either tabetics or paretics, seems to confirm the view that there is a neuro-
trophic strain of syphilitic virus, as the French observers believe.

The course of the juvenile form is remarkably protracted and is not
infrequently complicated in the later stages by the mental changes of
general paralysis. In this w^ay many cases probably escape recognition.

Any of the symptoms of the disease as it is seen in adults may occur in
the juvenile form, but on the whole the latter has a symptom grouping of
its own.

The onset is very insidious and the most constant early symptom
appears to be incontinence of urine. The next most frequent is optic atrophy,
which is found sooner or later in the great majority of cases. The character-
istic pupil changes of tabes are also seen in juvenile cases, but ocular palsies
and diplopia are rare. Headache is a very common symptom, and although
lightning pains occur, they are perhaps not so constant or so severe as in
adult cases. Girdle pains and gastric crises are also less common. The
objective sensory changes are like those of adult tabes, but are apt to be
less extensive. The knee-jerks are lost in the great majority of cases, but
ataxy is a symptom of exceeding rarity.

Parker analyses seven observed cases, which he studied in the Mayo
Clinic to which he is attached. He notes a feature not recorded in the
literature, namely, well-marked hj^potonus. In four, the pupils were com-
pletely immobile, and mydriasis was the rule. In all, the course was slow.

F. M. R. W.

Naccabati, S. The oculo-cardiac reflex (Dagnini-Aschuer phenomenon) —
its use in medicine and psychology. Arch. Neurol. 4' PsycMat, 1921, 5, 40.

Described by Dagnini and Aschner independently in 1908, the phenome-
non consists in slowing of the pulse, lowering of the blood-pressure, and
alteration of the rhythm of respiration on compression of the eyeballs.

Experimental observations indicate that the phenomenon is a true reflex,
the afferent path of which is the fifth nerve, and the efferent path the vagus
and possibly also the cervical sympathetic.

The reflex has been widely used on the Continent as an empirical sign
in various nervous diseases, but with conflicting results, except possibly in
the case of tabes in which it is universally found to be absent.

The standard commonly accepted as normal is a slowing of from five to
twelve beats per minute in the pulse-rate. Greater slowing is regarded as
an exaggerated response, less as a diminished response.

To obtain the reflex, the patient is placed in the recumbent posture or
lying back in a chair. When the pulse-rate has become constant, the eye-
ball is compressed through the closed lids by the thumb and index finger of
the right hand. The pulse-rate at the wrist is simultaneously taken by
the observer. Naccarati finds great variations in the same individual at
different times, hence the difficulty in establishing a normal standard, and
he suggests that the difference between the pulse-rates sliould be recorded
with and without pressure, with a plus or minus sign. This figure he calls
the reflex index ; thus a slowing of twelve beats per minute is recorded as
+ 12. Observations were made upon 500 subjects, healthy and abnormal.

NEUROLOGY 151

Of the normals, 40 per ceut. showed a positive index ot" from to 4. In the
remainder the index was variable. A single observation is said to be of
little value, and repeated tests are necessary to establish an average.

Naccarati adds a list of factors, both physiological and psychological,
which influence the character of the response in normal subjects, and it
becomes clear from his observations that the oculo-cardiac reflex has no
diagnostic value whatever.

It is unfortunate that he docs not say this at once, and thus put in its
proper perspective a phenomenon which has cumbered neurological litera-
ture unduly. Instead, he goes on to say that ' it may constitute an index of
the psychic condition and of the sympathetic-endocrine make-up of the
subject, but only when other factors have been standardized. In normal
persons the reflex index may serve as an indication of reflex control, moods,
courage, emotions, &c., traits whose scales are wanting.' All of which means
precisely nothing.

It seems characteristic of the craving for new and bizarre ' signs ', for
ever fresh empirical diagnostic tricks, that it gives rise to an extensive and
unscientific literature, which rises mushroom-like as each new phenomenon
is recorded. The quotation given above from Naccarati's paper is typical of
the scientific value and general style of the papers in which these new
signs and wonders are proclaimed.

The atrocious phrase ' sympathetic-endocrine make-up ' is an epitome
of this class of neurological literature, to which, fortunately, this country is
not addicted.

The therapeutic value attributed to the phenomenon in controlling
paroxysmal tachycardia is not dealt with. F. M. R. W.

DE EiiEiJiT, A., u. Magnus, R. Labyrinthreflexe auf Progress] vbewegungen.
[Labyrinthine reflexes to progressive movements.] Arch. f. d. ges. Physiol.,
1921, 186, 39.

Various progressive reflex movements which are connected with
particular spatial movements fail if the labyrinths are destroyed, but
persist if the aft'erent nerves to the muscles concerned are divided, or when
either the cerebrum or cerebellum is removed. It is concluded that the centres
for such movements dependent on the integrity of the labyrinth are some-
where in the brain-stem. Destruction of the otoliths l)y centrifugation
leaves these reflexes intact ; they arise therefore from the semicircular
canals and not from the utricle and saccule. The function of the semi-
circular canals is always concerned with response to acceleration, either
angular or rectilinear, as contrasted with the static functions of the maculae
and otoliths. C. L. E.

DE Kleijit, a, Tonische Labyrinth- und Hulsretlexe auf die Augen. [Tonic
labyrinthine aaxd neck reflexes of the eyes.] Arch. f. d. ges. PhgsloL, 1921,
186, 82.

Tonus of the eye muscles depends on the position of the head ; (a) in
space (labj^rinth reflexes), and (h) with relation to the neck. The latter
reflexes persist after bilateral destruction of the labyrinth. As a result of
these two types of reflex, the eyes tend to maintain a constant position in
space, i.e. an unaltered visual field. C. L. E.

M 2

152 ABSTRACTS

DE EI.EZJN, A., u. Magnus, R. tJber die Funktion der Otolithen. I. Oto-
lithenstand bei den tonischen Labyrinthreflexen. II. Isoliei-te Otolithenausschalt-
ung bei Meerschweinchen. [On the functions of the otoliths. I. The place
of the otoliths in tonic labyrinth reflexes. II. Separate removal of the
otoliths in the guinea-pig.] Arch. f. d. ges. Pliysioh, 1921, 186, 6 and 61.

(1) The experiments were carried out in rabbits. The general con-
clusion, which is not at variance with clinical findings, is that the maculae
are sense organs which respond principally to traction. When the otolith
is horizontal, and dependent from the macula so as to pull upon it, the
impulses set up are at a maximum ; when the position is reversed, so that
the otolith lies directly over the macula and presses on it, the afferent
impulses from the latter are at a minimum — whether they disappear
altogether is undecided. The sensory apparatus and its afferent path,
together with the tonic reflexes of position with which it is concerned, appear
to be quite incapable of fatigue. Tonic labyrinthine reflexes of the ex-
tremities, neck, and trunk are originated in the utricle, and asymmetric
postural reflexes in the saccule. The site for initiation of symmetrical
postural reflexes may be either or both. Vertical compensator}^ eye-move-
ments originate from the main saccule otolith, and rotatory ones from
the independently innervated angle of the saccule. The experiments,
when taken in conjunction witli the authors' previous work on the labyrin-
thine reflexes, give certain indications as to the central connexions of the
various branches of the vestibular nerve. Thus the path for tonic labyrin-
thine reflexes is connected behind the entrance of the eighth nerve with
the centres for the muscles concerned, while that for labyrinthine postural
reflexes passes to the posture-centres in the mid-brain. The path for the
impulses governing vertical compensatory eye-movements is to the nucleus
of the superior rectus of the same and inferior rectus of the opposite side ,
while that for the wheel-movements is to the nuclei of the inferior oblique
and trochlearis. There are many good examples of reciprocal innervation
in these labyrinthine reflexes. No definite participation of the semicircular
canals in these reflexes could be demonstrated.

(2) When guinea-pigs are rotated in a centrifugal apparatus at the rate
of 1,000 revolutions per minute for 1 to 2 minutes, the static postural tonus
functions of the labyrinth are frequently lost, while the labyrinthine responses
to movement are retained. When this happens it is found that the otolith
membranes have been detached, while the cristae of the semicircular canals
have remained intact. This experiment, in which definite clinical features
are recalled, thus supports the belief that the utricle and Saccule are con-
cerned with static equilibrium, while the semicircular canals are the
corresponding organs for dynamic co-ordination. C. L. E.

PATHOLOGY AND BACTERIOLOGY

BI.AKE, F. G., and CeczIi, IIussei.i. L. Studies on experimental pneumonia.
IZ. Production in monkeys of an acute respiratory disease resembling
influenza by inoculation with Bacillus influenzae. J. Exper. 31., 1920,
32, 691.

PATHOLOGY AND BACTERIOLOGY 153

CeciIi, RusSEiJi L., and Bi.ake, F. G. Studies on experimental pneumonia.
X. Pathology of experimental influenza and of Bacillus influenzae pneu-
monia in monkeys. -/. Exyer. M., 1920, 32, 719.

The important researches on pneumonia by the authors have ah-eady
been abstracted in Medlml Science (1920, 3, 63, 358 ; 552). The present,
their ninth paper, deals with the production in normal monkeys of an acute
respiratory disease following the inoculation of B. influenzae on the mucous
membranes of the upper respiratory passages and of broncho-pneumonia
from intratracheal inoculation. One strain of B. influenzae was used
throughout these experiments and was originally raised in pure culture
from the suppurative pleural exudate of a child, the subject of influenzal
pneumonia. A preliminary intratracheal test inoculation of a monkey
having shown that the microbe was non-pathogenic, an attempt was made
to exalt the virulence by passage. This was attained through a series of
eleven white mice followed by a series of thirteen monkeys. Large doses
were used to begin with, but at the completion of the series a dose of
0-1 c.c. of a 16-hour blood broth culture from the peritoneal exudate of the
passage monkey No. 13 killed a white mouse within 48 hours. In the
subsequent experiments two species of monkey were used, viz. Cehus
capucinus and Macacus syrichtus. Two methods of inoculation were
employed with different purposes in view. In order to find out whether
B. influenzae would initiate an infection of the upper respiratory passages,
material was introduced into the nose either by means of a pipette or by
a swab dipped in the culture medium. In a second series the culture was
injected directly into the trachea. The clinical history and post-mortem
appearances of twelve monkeys treated by the first method of inoculation
are carefully given. A respiratory disease was produced of 3 to 5 days'
duration characterized by sudden onset with profound prostration, the
development of rhinitis and tracheo-bronchitis with cough, sneezing, and
the presence of a scanty mucoid or muco-purulent nasal discharge. In five
instances suppuration of one or both antra occurred, and in three there was
a broncho-pneumonia. Sometimes there was a definite leucopenia. Bacillus
influenzae was recovered at autopsy from the lesions of the disease and
was either in a pure state or associated with micro-organisms known to be
normal denizens of the upper respiratory tract of monkeys.

Of ten monkeys injected with cultures of B. influenzae into the trachea
seven developed broncho-pneumonia, two had tracheo-bronchitis alone, and
one was unaffected. The general symptoms and duration of the disease
were similar to those observed in the first group of experiments. The
authors consider that the experimental disease is, in its essence, identical
with human influenza.

In their tenth paper the authors carry the matter farther by dealing
in detail with the pathological findings in the respiratory infections caused
by inoculation of B. influenzae. This part of the research is illustrated by
eight plates of excellent photographs exhibiting the lesions. They empha-
size the fact that influenza in man is almost never a fatal disease unless
complicated by pneumonia, and on this account little opportunity has been
oflered of studying the changes of the pure influenzal disease, wdiich
appears to be a local infection of the upper respiratory tract with absorp-
tion of toxic products which cause the general symptoms. In experimental
influenza in monkeys the pathological changes do not essentially differ from
those that are met with in man. In both there is an acute catarrh

154 ABSTRACTS

extending from the nasal cavities into the trachea and bronchi. A broncho-
pneumonia is a frequent complication. The observations of morbid anato-
mists have shown that influenzal pneumonia possesses certain characteristic
features, of which the most important are intense engorgement, haemo-
rrhage, and oedema, with purulent bronchiolitis and scattered foci of peri-
bronchial consolidation. Cecil and Blake describe these same changes in
monkeys infected with cultures of B. influenzae, although in the latter it
is usually a milder affection than in man. Attention is drawn to the fact
that the pathogenesis of pure influenzal pneumonia is difterent from that
induced by pneumococcus or streptococcus. In influenza, both natural and
artificially produced, the infection seems to travel into the bronchioles,
and subsequently involves the alveoli by contiguity, whereas in pneumo-
coccus and streptococcus pneumonia the microbes quickly penetrate the
bronchial mucous membrane and spread rapidly through the perivascular
lymph spaces to the alveolar walls in all parts of the lobe.

All observations go to show that influenza bacilli possess but trivial
invasive properties when compared to organisms like pneumococcus or
streptococcus. The authors also note that in experimental infections by
B. influenzae in monkeys there are changes in the thymus gland, including
hyperplasia of the follicles, distension of the lymphatic channels, and infil-
tration of the parenchyma with leucocytes. These changes, however, are
apparently part of a general hyperplasia of lymphoid tissues in the cervical
and thoracic regions. The authors are to be congratulated on having greatly
advanced knowledge on experimental pneumonia in their long series of
researches, admirably conceived and cari'ied out with great technical skill.

W. B.

Maitlakd, H. B., CowAxr, Mary L., and DetwiszIiEB, H. K. Spontaneous
and artificial pulmonary lesions in guinea-pigs, rabbits, and mice. Brit.
J. Exper. Path., 1921, 2, 8.

A pulmonary lesion in guinea-pigs has been described which was
characterized by haemorrhage into the alveoli and sometimes into the
bronchioles. There was no leucocytic reaction in the lung-tissue, and no
haemosiderin was present in the cells of the lung. This lesion is an agonal
phenomenon. The same lesion occurred in rabbits and in mice, and is con-
sidered in them to be also an agonal phenomenon. Killing by rapid
chloroform anaesthesia produced fewer agonal lesions than a blow on the
back of the head. A method of killing has been described by which
haemorrhage was not produced. A second type of lesion has been noted
which is essentially a slow proliferation of endothelial cells. It is a
spontaneous animal disease whose origin is undetermined. The haemo-
rrhagic and proliferative lesion frequently occurred in the same area, but
neither was dependent on the other. B. bronchisepticus was isolated from
the lungs of sixteen guinea-pigs, but it was not possible to associate its
presence with the proliferative lesion. P. F.

Stillman, E. G., and Boubk, Janet M. Biological study of the haemo-
philic bacilli. J. Exper. M., 1920, 32, 665.

In 1919 Pritchett and Stillmann called attention to the existence of
haemophilic bacilli almost indistinguishable from B. influenzae except by
the fact that they can haemolyse blood. The present research is a further

PATHOLOGY AND BACTERIOLOGY 155

study of haemolytic bacilli, and includes a comparison of B. influenzae with
haemolytic Ixicilli (now called Bacillus X) and with B. 2)ertussi><, B. hronchi-
aepticus, and the hacillus of rabbit septicaemia. The haemophilic bacilli
can be subdivided into two groups according to the ability of certain
strains to produce haemolysin and consequent laking of blood. Both groups
may be further subdivided according to the ability of some strains to pro-
duce indol, to form gas, and to ferment certain carbohydrates. The bacilli,
of both groups, when grown in meat infusion bouillon containing 1 per cent,
of dextrose, reach a final hydrogen-ion concentration of about Ph 6-4.
Almost all the strains can reduce nitrates to nitrites. The haemolysin of
the lytic group is stated to be very stable, retaining its activity after being
kept on ice up to several months. It can be demonstrated in a young broth
culture only two hours old. It is non-filterable and is destroyed in half an
hour at 56° C. The haemolytic, haemophilic bacilli are not pathogenic for
guinea-pigs, rabbits, or mice. W. B.

Bex.1., H. H. Relation of different strains of influenza bacilli as shown
by cross-agglntination and absorption tests. J. Infect. Bis., 1920, 27, 464.

In this investigation twenty-seven rabbits were immunized with as
many strains of B. influenzae, live of which were obtained from normal
persons, while twenty-two were recovered from cases of influenza. Each
serum was then titrated with 36 cultures in dilutions varying from 1 : 25
to 1 : 6400. Absorption tests were also carried out. The author's results
are presented in a series of tables from which it emerges that the influenza
bacillus represents a heterologous group of micro-organisms as shown by
agglutination and absorption tests. It was impossible by such methods to
difterentiate between influenza bacilli vegetating in the throats of normal
persons and those isolated during the actual disease itself. A person may
actually carry in the throat three different strains at one and the same
time. W. B.

CooxE, J. V. Complement fixation in influenza with B. influenzae antigens.
J. Infect Bis., 1920, 27, 476.

This paper deals with complement-fixation tests in children and adults
suffering from influenzal pneumonia. Although complement-fixing anti-
bodies were obtained in the serum of a considerable number of older
children and adults convalescent from the disease, they were found with
much less constancy in children from 1 to 5 years of age. Further, no
definite antigenic relationsliip could be detected between the sera tested
and the 16 strains of influenza bacillus. W. B.

LoEWEKHARDT, P. E. R. Zur Aetiologie der Influenza. [On the aetiology
of influenza.] CentralU. f BaMeriol. (&c.), Abt. I, 1920, Orig. 85, 81.

The author, who is assistant in the Hygienic Institute of the University
of Breslau, under R. Pfeiffer, gives a lucid account of the epidemic of influ-
enza as it* affected Breslau in 1918, 1919, and 1920, and shows that the
incidence of B. influenzae Pfeiffer showed a striking correspondence with
the individual epidemic outbursts. In 187 cases of influenza, influenza
bacilli were found in 65*62 per cent., viz. 57-14 per cent, in cadavera, 76*25
per cent, in sputum, and in 52 per cent, when the material was taken from

156 ABSTRACTS

the throat. When the material from the throat was examined at the actual
bed-side, influenza bacilli were found in 91-11 per cent, of the cases. Material
examined 4-6 hours later yielded a positive result in only 30-4 per cent, of
the cases, whereas examined 24 hours later the results were completely
negative as far as concerns B. influenzae. Of 397 non-influenzal cases only
35 (8-81 per cent.) showed influenza bacilli in the sputum, while of 101
throat examinations only 5 (4-95 per cent.) were positive, the percentage
for the whole series of 498 non-influenzal cases being only 8*03. The
author lays great weight on the bacteriological examination being carried
out immediately, and on the use of pigeon's blood agar as the culture
medium — Pfeiffer's original recommendation. W. B.

FiTTKAM, J. J., and Gay, D. M. Behaviour of the influenza bacillus in
mixed culture on haemoglobin-free media. J. Med. Research, 1920, 42, 1.

The authors attempted to grow B. influenzae, on a variety'' of blood-free
media, in association with B. xerosis, B. diphtheriae (4 strains), Diplococcus
'pneumoniae (3 strains), B. coli, and two strains of a saprophytic staphylo-
coccus. Sixteen cultures of B. influenzae were tested. The media employed
were nutrient agar, with or without glucose, Martin's agar, glycerine egg
medium. In the majority of instances the influenza bacillus failed to grow,
and in fact the influenza inoculum died out. W. B.

FzLDES, F. The nature of the effect of blood-pigment upon the growth of
B. influenzae. Brit. J. Exper. Path., 1921, 2, 16.

(1) Growth of B. influenzae has not been observed to occur in the
total absence of blood-pigment. (2) The quantity of blood-pigment neces-
sary is small, but larger than has been stated. (3) Probably oxy haemoglobin
and carboxyhaemoglobin are incapable of allowing growth, the feeble multi-
plication in these pigments being due to a spontaneous change to methae-
moglobin. Haematoporphyrin also fails to permit growth, but haematin
allows a copious growth. (4) B. influenzae on suitable media grows fairlj'
well under anaerobic conditions, but rapidly dies out. The necessary
oxygen is obtained from an oxygen store in the medium. This store is not
dissolved active oxygen, but is inactive in a state of loose combination with
a constituent of the medium. Under aerobic conditions the combined
oxygen is used up by the bacillus and immediately re-formed from the
atmosphere. (5) The combined oxygen in the medium is activated for the
bacillus by the catalytic action of iron in the pigment. (6) The feebleness
of the growth on unchanged blood compared with that upon changed blood
is due to a deviation of the oxygen, activated by the iron of the pigment,
from the bacillus through the oxygen affinity of the unchanged pigment.

P. F.

OXiSEH, O. Ueber die Bedeutung des Blutes fiir das Wachstum des Pfeilfer-
schen Influenzabazillus. [The action of blood in the growth of the influenza
bacUlus.] Centralhl. f. BaUeriol. (&c.), Abt. I, 1920, 85, 12.

B. influenzae was found to grow equally well upon media containing
pure crystallized horse haemoglobin and methaemoglobin as upon whole
horse blood, in the familiar minute colonies. With pure haematin, however,
growth was never obtained except in associated gi'owth with other bacteria;

PATHOLOGY AND BACTERIOLOGY 157

on the other hand, haeinatoporphyrin did not allow growth under any
circumstances. Thus iron-containing pigment was necessary for growth.

From these experiments the author thought that independent growth
of B. injluenzae might depend upon the oxygen-carrying capacity of haemo-
globin. He sought to show that the oxygen of haemoglobin might be
utilized by the bacillus in its growth, by demonstrating a reduction of the
pigment in the deeper layers of a ' deep ' agar culture, such reduction being
ob'served by him only in inoculated tubes. Such a function of haemo-
globin was, however, obviously improbable in view of the equal growth
with methaemoglobin, a pigment without oxygen-carrying capacity.

Next, the- author observed that growth of the bacillus ran parallel to
the catalytic action of the necessary pigment. Thus haemoglobin, met-
haemoglobin, and haematin were catalytic, but^not haematoporphyrin. He
concludes that the function of the pigment is probably to activate oxygen
for the ffrowth of the bacillus. P. F.

Smith, J. D., and Wilson, M. A. Comparison of smear, culture and com-
plement fixation in chronic gonorrhoea in women. J. Immunol, 1920,
5, 499.

This is a short paper based on 50 cases diagnosed clinically as mild
chronic conorrhoea, and 58 controls that were considered clinically not to be
gonorrhoeal.

The antigen used was made from gonococci grown on disodium
phosphate agar. These were treated with alcohol to remove lipoids, dried,
weighed, powdered, and suspended in saline, 1 grm. to 200 c.c. This
suspension was heated in a water-bath at 80° C. for 1 hour and then
standardized. This antigen is said to be stable.

The culture tests were carried out on glycerine serum agar smeared
with blood.

Of the 50 cases diagnosed clinically as mild chronic gonorrhoea only 7
were positive in film or culture ; while 23 gave a positive complement
fixation, 18 gave a weak positive and 9 were doubtful or negative.

The 58 controls were not examined by films or cultures and they all
gave negative complement fixations.

It is concluded that a non-gonorrhoeic serum does not give a positive
complement-fixation test, but a negative fixation test cannot exclude a chronic
gonorrhoeic infection. The investigation, in part, was carried out in the
Bureau of Laboratories of the Department of Health, City of New York.

G. T. W.

Thomsen, O., and Voi.i.mon'D, E. Forsog paa Typeindeling af Gonococcer.
[An attempt to classify gonococci according to type.] Hosp.-Tid., 1920,
63, 681-96.

Thomsen and VoUmond have attempted by agglutination and comple-
ment-fixation tests to distinguish various types of gonococcus. Their
material consisted of 26 cultures of gonococci obtained from as many cases
of recent urethritis in men. They soon found that complement fixation
gave the most reliable and unequivocal results, and they noted that various
cultures of gonococci were more or less easily agglutinated by the same
quantity of agglutinin. By combining absorption with complement fixation,
instead of relying on the combination of absorption plus agglutination, they

158 ABSTRACTS

were able to obtain the required information in a few hours, whereas 24
hours were necessary for the latter test, owing to the slowness of agglutina-
tion. With agglutination or complement fixation alone, they were unable
to distinguish marked differences in the reaction of the various cultures to
specific antisera. But when they combined these tests with that of
absorption, they were able to classify the 26 cultures in 3 groups (types a,
h, and c, including 14, 5, and 5 cultures each). The remaining 2 cultures
could not be fitted into any of the above classes. Comparing their investi-
gations with those of K. W. Jotten (vide Medical Science, 1921, 3, 359),
Thomsen and Vollmond note that this worker appears to have relied on
agglutination and complement fixation only, and not to have employed the
supplementary method of absorption. With regard to a possible relationship
between the serological and clinical characteristics of their 3 types of
gonococcus, Thomsen and Vollmond state that of the 14 cases belonging to
type a, 5 were complicated by epididymitis and prostatitis, and the disease
was protracted. Three cases were clinically slight, and 6 could not be
traced. Of the 5 cases belonging to type b, 3 were very slight and 2 were
very protracted. All of the 5 cases belonging to type c were slight and
uncomplicated. C. L.

FoNTAiTA, A., e Sanoxoboi, G. Sugli spironemi dei condilomi acuminati.
[On spironemata of pointed condylomata.] Pathologica, 1920, 12, 293.

Investigations were made in 20 different cases chosen among non-
syphilitic subjects. The authors have been able to identify three forms of
Spii'onema. The first one is termed by them Type A, and corresponds
morphologically to the >S/j. refringens of Schaudinn and Hof mann ; the second
is spoken of as Type B, and is similar to that found by Sangiorgi in 1916
in the human intestine; the third form is characterized by its similarity
with the genus Trepone'nia, and is very likely identical with the IVep.
calligyrum described by Noguehi. C. d. F.

Spiethoff, B. Beitrag zu den Fehlerquellen bei der Salvarsanbehandlung.
[The sources of error in treatment by salvarsan.] Berl. JcUu. Wchnschr.,
1921, 58, 8.

In recent years there have been many records of untoward effects follow-
ing the use of salvarsan. These include particular complications on the part
of the liver, or of the nervous system. The present author was one of the
early observers (1910) of salvarsan fatalities. In the communication now
before us he reports the frequent occurrence of hepatic and nervous injuries,
These made their appearance in an insidious manner from September 1913
onwards, and in the middle of 1914 actually 50 per cent. (!) showed jaundice.
In this period he was using salvarsan dissolved in the patients' own serum,
as experiments seemed to indicate that this combination was less toxic than
watery solutions of the drug. At first jaundice was seen in those who had
received a considerable number of salvarsan injections, later it occurred
after a few. At one time there were no hepatic complications with watery
solutions of salvarsan, but at the height of the 'epidemic' two cases of
jaundice occurred even with these. Investigation showed that the same
syringes were used both for the serum and for the watery salvarsan
solutions. After use the syringes had been well washed in water, dried in

PATHOLOGY AND BACTERIOLOGY 159

air, and were kept in boxes with formalin tabloids. The replacement of
these syringes by new ones is alleged to have been the cause of the cessation
of the complications.

Neurotropic complications, such as symptoms of mening-itis, lesions of
a single cranial nerve, or severe psychoses, also made their appearance in
groups of cases, and during courses of treatment which previously had been
administered without detriment. These courses were in three stages: (1)
a total of 6 grm. of salvarsan was injected (period of time not stated) ; (2) a
10 weeks' course of mercury in some form : (3) a last course in which
a total of 3 to 4-5 grm. of salvarsan was given. Reference is made to 19
cases in which there were ' cerebral ' complications. In 7, viz. 4 females and
3 males, the sj^mptoms appeared in the second half of the first salvarsan
series of doses. In 7 females the symptoms developed after the first dose
of mercury, i. e. at the beginning of the second stage of treatment, while in 4
cases (3 females and 1 male) they appeared in the middle of the mercurial
stage. Of the 19 cases, 15 were females and 4 were males. It is suggested
by the author that in some mysterious way the complications were due to
syringe * errors ', the instruments, in addition to salvarsan injections, having
been used for injections of a calcium preparation called * Afenil ', the
nature of which is not stated. The use of new syringes again caused
a cessation of the cerebral complications. The cases of icterus were all
mild and there was no instance of acute hepatic atrophy. The author
discusses the possibility of the syphilis infection itself being partially
accountable for the complications, but is unable to make any definite
assertions. W. B.

NiNNi, C. Sulla forma delle spore dei batteri del suolo. [On the size of
spores of the bacteria of the soil. J PatMogica, 1920, 12, 316.

If the earth of gardens or other soils be bacteriologically investigated,
minute bodies are seen which have all the characteristics of ordinary spores
with the exception of the size, which is only about half that of the ordinary
ones. These small spores can be obtained artificially if sporogenous bacilli ;
for instance, B. anthracoides are cultivated by Pane's method on agar
prepared with sterile water, and cultures kept for 24 hours at from 7° C. to
11° C. The author thinks that the small size of such spores is due to the
relatively low temperature of the soil, because the same bacilli produce
spores of the ordinary size if the cultures are left for another 24 hours at
31° C. This phenomenon cannot be in relation to nutritive conditions,
because Pane has shown that B. anthracis produces spores of normal size if
cultivated at 33° C. in distilled water. C. d. F.

Capone, G. Sulle variazioni della flora anaerobica in alcuni stati morbosi
deir intestino. [Studies on the anaerobic flora in some morbid states of
the intestine.] Sperimentale. Arch, di hiol., 1920, 74, 54.

Systematic investigations on the morphological and cultural properties
of the anaerobic flora of human intestine were carried out by the author,
who for this purpose has examined samples of faeces of 12 healthy subjects,
of 15 cases of bacteriologically ascertained forms of bacillary dysentery, of
4 cases of typhoid fever, and of 15 cases of enterocolitis. The cause of the
latter could not be ascertained, as all investigations for protozoa, dysenteric

160 ABSTRACTS

or paratyphoid bacilli, and the like were attended with negative results, the
aerobic flora of these cases appearing to consist chiefly of coliform bacilli.

The normal anaerobic flora appeared to be essentially formed by
B. perfringens, which was found in almost all samples investigated. More-
over the following forms were identified : In two cases B. sporogenes of
Metchnikofl" (Strains P. 8-P. 11). In one case a bacillus similar to the
variety B of B. sporogenes (P. 10). In another case B. 'putrijicus of
Bienstock (P. 16). In two cases, forms intermediate between B. 'putrijicus
and B. para-putrijicus (P. 18-P. 19). Each of the following were seen
once: B. sporogenes non-liquefaciens of Jungano (Bm. 25) ; a form similar
to V. septique of Pasteur (Bm. 4) ; a strain similar to the bacillus of pseudo-
oedema of Liborius-Sanfelice (Bm. 10) ; an unclassified anaerobic form
(P. 22) ; and finally the Clostridium, foetidum of Liborius-Sanfelice (P. 3).

The following strains were isolated from cases of dysentery ; B. per-
fringens, frequently ; a similar strain, once ; strains similar to B. Ill of
Rodella and Species IX of v. Hibler, four times ; strains identical with
B. sporogenes non-liquefaciens of Jungano, twice ; a strain similar to B. IV
of Rodella, once ; strains similar to V. septique of Pasteur, thrice ; a non-
identified putrefying form, once.

The investigations made on samples from cases of enterocolitis were
attended with similar results. The anaerobic flora of cases of typhoid fever
was found to be chiefly formed by B. perfringens and putrefjdng forms ;
Clostridium foetidum, B. sporogenes, and a non-identified putrefying form
were each found once.

From these results the author draws the conclusion that B. perfringens
is constantly present in the human intestine and that the various circum-
stances which contribute to modify the flora of human intestine appear to
have no influence on B. perfringens, but a considerable one on putrefying
strains, which may in certain morbid states remarkably diminish in number
and even completely disappear. C. d. F.

NzNNX, C. Un nuovo bacillo anaerobico del suolo [B. spermoide). [A new
anaerobic bacillus of the soil {B. spermoides). Fathologica, 1920, 12, '686.

The new bacillus was isolated by the author from the soil of a high
mountain (Mount Scagliolo), and is termed by him B. spermoides because of
its morphological resemblance to the human spermatozoon. B. spermoides
is pathogenic for the guinea-pig, in which it produces a form of chronic
cachexia, but no tetanic symptoms of any kind. It is similar to B. tetani,
but it can easily be distinguished from the latter because it is longer and
larger, and because of various cultural characteristics, among which there is
an acid formation, in any anaerobic medium, without the repugnant smell
of B. tetani.'^ C. d. F.

HEX.I.EB, HiiiSA Hempi.. Aetiology of acute gangrenous infections of
animals: a discussion of blackleg, braxy, malignant edema, and whale
septicemia. J. Infect. Dis., 1920, 27, 385.

This is an important contribution to the difficult and involved question
of acute gangrenous anaerobic infections in animals, especially cattle, horses,

* It may be pointed out that according to the Report of the Committee upon Anaerobic
Bacteria (Medical Research Committee, Special Report Series, No. 39, 1919), p. 28, pure cul-
tures of £. tetani have a characteristic but not a putrefactive odour.

PATHOLOGY AND BACTERIOLOGY 161

sheep, pij,'s. The authoress has manifestly made a most searching inquiry
into the enormous and unsatisfying literature which has accumulated round
these diseases, and she does not hesitate to pronounce most trenchant
criticism where it is recjuired. This renders her work all the more valuable
in comparison with the numerous papers which are constantly pouring out
with extensive bibliographies in which every observation by whomsoever
made is treated with equal respect. Throughout her bibliographic studies
are constant observations of her own, which clearly show that she speaks
with authority. The confusion into which the bacteriology of anaerobes
had fallen before the war was clearly stated by Weinberg and Seguiu and
was tlie principal cause which led the Medical Research Committee to
institute a special committee of inquiry on anaerobic bacteria. This body
aided materially in clearing up the confusion as far as concerns human
pathogenic anaerobes. The present authoress has attempted something of
the same kind w'ith the even more uncertain and inadequately studied
pathogenic anaerobes of animals. The paper, however, must be read in the
original by workers on anaerobes, as it cannot be adequately dealt with here.

W. B.

House, S. John. Haemorrhagic meningo-encephalitis in anthrax : a report
of three cases. -/. Infect. Dis., 1920, 27, 513.

The author gives a good description of three cases of cerebral com-
plications occurring in anthrax. In two, the disease was not even suspected
during life. The lesions were essentially extravascular, meningo-encephalitic,
and the acute haemorrhagic non-purulent nature of the inflammatory
exudate was like anthrax elsewhere. Large numbers of anthrax bacilli
were found in the lesions. Two of the cases occurred in ' curled hair '
workers who ultimately contracted intestinal anthrax, whereas the third —
a boy of 15 — seemed to have had no direct connexion with anthrax-infected
products. A clinical diagnosis was not made, but mastoid abscess with
lateral sinus thrombosis was suspected. The cerebral infection was believed
to have been by the haematogenous rather than by the lymphogenous route.

W. B.

FuKUDA, A. Experimentelle Untersuchungen fiber Milzbrandinfektion bei
Ratten. [Experiments on anthrax infection in rats.] Centralbl.f. BaJcteriol.
(&c.), Abt. I, 1920, Orig. 84, 516.

In the last decade of last century, a great deal of labour was expended
on the study of the action of anthrax bacilli on the highly immune rat, and
many experiments were undertaken to investigate the methods by which
the natural immunity could be broken down, and the animal rendered
susceptible to anthrax. The present author, working in the Hygenic
Institute in Zurich, has again made a study of this question, and especially
the influence of calcium chloride, which was shown by Bullock and Cramer
to increase the liability to tetanus and other anaerobic bacteria. Instead of
rendering rats more susceptible to anthrax, his experiments go to show that,
in quantities of 0-001 to 0-03 grm., calcium chloride injected simultane-
ously with anthrax culture retards, as a rule, the course of the disease. He
also finds that anthrax bacilli injected into rats already infected with
nagana tiypanosomes, has a delayed effect. There was also an apparent

162 ABSTRACTS

antagonism between B. anthracis and i?. lyyocyaneus — an old view revived.
Starting with a culture which was only slightly pathogenic for the rat, the
author, by means of 12 rat passages, raised the virulence so that ^ of a loop-
ful of a culture on agar killed rats constantly in 27 to 54 hours. It was
with such virulent cultures that the above experiments were carried out.

W. B.

IiUBXNSXi, H. (1). Bakteriologisches zur Frage der Wunddiphtherie. [Bacterio-
logy of wound diphtheria.] Bed. Mm, WchnscJir., 1920, 57, 1154.

LUBXNSKZ, H. (2). Bakteriologische Untersuchungen fiber Wunddiphtherie.
[Bacteriological researches on diphtheria of wounds.] Centralbl. f. Bakteriol.
(&c.), Abt. I, 1920, Orig. 85, 96.

These two papers deal with one and the same material, the first being an
abrido-ement of the second. The bacteriolog-ical examination of wounds
revealed in a number of instances the existence of bacilli, presenting close
resemblance with B. diphtheriae. A closer investigation showed, however,
that only a certain number were genuine diphtheria bacilli, a considerable
proportion differing in the fact that they were able to ferment saccharose
and that they were non-pathogenic The author calls this organism para-
diphtheria bacillus. Of 105 samples from wounds, 18 showed true
diphtheria bacilli, and 46 were of the saccharose-fermenting paradiphtheria
type. Of the true diphtheria bacilli found, 10 were found to be non-toxic.
The author regards paradiphtheria as harmless for animals and quotes an
experiment in which the same is probably true for man. A quantity of
0*05 c.c. of a paradiphtheria strain grown 10 days in bouillon was injected
intracutaneously into a human being without result. In future examina-
tions of diphtheria in wounds he emphasizes the necessity of testing not only
the toxicity but also the fermentation results on a number of carbohydrates,
particularly saccharose. W. B.

Gronberg, J. Studier ofver blodfermenten vid graviditet, karcinom och
lungetuberkulos. [Studies of the blood ferment in pregnancy, carcinoma
and pulmonary tuberculosis.] Finslca LdJc-sallsk. HanclL, 1920, 62, 599-631.

Gronberg, whose investigations were made under Abderhalden in Halle,
and Granberg in Viborg-. classifies the literature of Abderhalden's test
according as the authors obtamed good or bad results. The bibliography
for the first class occupies a page and a half, for the second a little more
than half a page. Much of his paper deals with technique, and he reiterates
the warning that, without meticulous care in every detail, the test is of
little value. He has tested collodium dialysers and found them unsatis-
factory. To ensure objectivity of judgement, he kept himself in ignorance
of the clinical diagnosis of the cases from which sera were obtained. In all
the 28 cases of normal pregnancy between the 1st and 9th month, a positive
reaction was obtained with placental tissue, whereas all the 19 control sera
from healthy, non-pregnant individuals gave a negative reaction to pla-
cental tissue. All the sera of 23 patients suft'ering from carcinoma in
various stages gave a positive reaction to a substrate obtained from car-
cinomatous liver with metastases. All the control sera of healthy persons
gave a negative reaction to the same substrate. All the sera of 34 cases of
pulmonary tuberculosis gave a positive reaction to a substrate obtained

PATHOLOGY AND BACTERIOLOGY 163

from tuberculous lunj,'s. Of these 34 cases, 8 were in Turban's first stage,
and 11 were in a still earlier stage, being merelj^ suspects. Gronberg
evidently considers that Abderhalden's test requires so great technical skill
that its practical utility is much limited. C. L.

Becker, G. Om komplementbinding hos botriocefalusbjirare. [Complement
fixation by the hosts of Bothriocephalus] F'mska LaJc-siillsIc. 1 fundi, 1920,
62, 632-47.

Becker's answer to the question : Does Bothriocephdlas give rise to
antibodies in the serum of its host ? is reserved. Probably it does so, but
the reaction is almost certainly not specific. He examined 58 persons
harbouring Bothrioceiihalus and 92 in whose faeces there were no signs of
it. He classifies the reactions according as there was no haemolysis, slight,
almost complete, or complete haemolysis. Including slight haemolysis
among the positive reactions, he found these in about 50 per cent, of the
Bothriocephalus carriers and in only about one-ninth of the healthy con-
trols. Some of these, he adds, may have harboured the Bothrlocepladas in
spite of the examination being negative. Positive reactions were obtained
when a Taenia antigen was tested with the serum of a Bothriocephalus
carrier, and when a Bothriocephalus antigen was tested with the serum of
a Taenia carrier. Hence Becker's doubts as to the specificity of the reaction.

C. L.

FxcAi, G. Osservazioni sierologiche sul tifo esantematico. [Serological
studies on typhus.] Ann. d'ig., 1920, 30, 395.

The agglutinins for Micrococcus melitensis do not appear earlier in the
blood than^those for B. 'pi'oteus X 19, and very soon disappear. The
Wassermann reaction is in most cases at first negative, but becomes positive
in the course of the disease and then negative again. The Wassermann
reaction has, therefore, no diagnostic value, but it may be useful in showing
the existence of profound modifications in the blood of typhus patients.
The diagnostic value of the Weil reaction is almost absolute; but the
•practical value is in strict relation to the sensitiveness of the strain of
B. proteus X 19 used. In practice it is useful to have at hand strains of
B. proteus X 19 of different origin, as some strains appear to have various
degrees of sensitivity when tested with the serum of patients coming from
different places. The studies of recent years prove that the virus of typhus
causes an intense reaction on the part of the organism during which agglu-
tinins, produced during other infectious already overcome, are brought into
action aofain. C. d. F.

ScHUTZE, H. Haemagglutination and its medico-legal bearing, with obser-
vations upon the theory of isoagglutinins. Brit. J. Exfper. Path., 1921,
2, 26.

The possibility of grouping dried human blood specimens by recon-
structing the serum for agglutination and using the undissolved residue
for absorption has been demonstrated. Forensically, the test would be of
most importance when proving dissimilarity between two specimens alleged
to be derived from the same source. To prove their similarity would
probably only be to furnish circumstantial evidence of more or less value

164 ABSTRACTS

according to the group in question and the frequency of the occurrence of
that group in the population concerned. The Landsteiner theory that two
substances, ' A ' and ' B ', with their corresponding agglutinins, ' a ' and ' b *,
are concerned in the isoagglutination of human bloods has been confirmed
by absorption tests. P. F.

EoDAMA, R. Ocular reactions in anaphylaxis. J. Infect. Bis., 1921, 28, 48.

Tliis is an interesting study of the anaphylactic effects on the eyes of
guinea-pigs sensitized with horse serum. Preliminary observations and
measurements were made on the width of the lids and the pupil, the iris
being examined by a magnifying lens under electric light. Measurements
are given showing the effect of instilling saline solution or normal horse
serum into the eyes of normal guinea-pigs, of normal horse serum, heated
or unheated, into the eyes of sensitized guinea-pigs, the injection of normal
horse serum into the orbits of normal and sensitized guinea-pigs, intravenous
injections of serum in normal and sensitized guinea-pigs, and other varia-
tions. Generally speaking, the application of normal horse serum to the eyes
of normal or sensitized guinea-pigs produces dilatation of the lids and pupils
succeeded by contraction. In the sensitized animal the response is more
prompt and vigorous. The primary dilatation appears to be the result of
stimulation of the tarsal smooth muscles of the lid and the dilator smooth
muscle of the iris. The secondary narrowing of the lid fissure may be
explained as due to the loss of tone of the tarsal muscle and dilator pupillae
on one hand, and to the contraction of the sphincter of the iris associated
with congestion on the other hand. The primary and secondary effects on
the smooth muscles of the lid and iris suggest that the anaphylactic action
involves the ends of both the true and parasympathetic nerve-fibres on both
sets of plain muscles in the lid and the iris.

Anaphylactic intoxication with horse serum may also be associated
with circulatory disturbances, such as oedema and congestion of the lid,
conjunctiva, iris, and fundus. The direct application to the eye of horse
serum, heated or unheated, may cause vascular dilatation in the normal,
but haemorrhage is observed especially in the sensitized animals. As it
takes place independently of asphyxia it is due to direct action on the
vessels. In addition to the characteristic post-mortem appearances of ana-
phylactic shock there is a rapid and strong contraction of the pupil after
anaphylactic death. As all the anaphylactic eye phenomena appear to be
an intensification of the reaction that follows the application of horse serum
to the eye of the normal guinea-pig the author suggests that the normal
animal possesses small quantities of the anti-substances necessary for the
anaphylactic reaction. W. B.

Howell, Eatkerine M., and Eby, Harriet. The transmission of specific
immune bodies from the mother to the young. J". Infect. Bis., 1920, 27, 550.

The authors carried out a number of experiments to determine : (1) the
effects of parturition on the antibody content of immunized rabbits ; (2) the
antibody content of the serum of the offspring of immunized rabbits ; and
(3) the durability of the immune bodies in the serum of the offspring of
immunized mothers. Six rabbits were employed, one being immunized
against human, the second against sheep's erythrocytes, the third against

»i

PATHOLOGY AND BACTERIOLOGY 165

Streptococcus virldans, the fourth against Dqulococcus pneumoniae (Type II),
the fifth against Micrococcus meningitidis, and the sixth against B. typhosus.
A hio-h deoree of immunity was maintained by a weekly dose of the im-
munizing agent during pregnancy, but this was discontinued after preg-
nancy. The blood of mothers and offspring was tested as soon after
parturition as possible. In the sera of the mothers antihuman and anti-
sheep lysins diminished after parturition. The sera of the offspring of
immunized mothers exhibited haemolj'sins, but in lesser amounts than that
of the mothers. In the young the lysins disappeared completely within
eleven weeks. For the most part the complement-fixing antiliodies,
opsonins, and agglutinins showed a like course. W. B.

Bbowking, C. H., and Wilson, G. Hasweli.. The antigenic properties of
globin with a note on the independence of the properties of serum and
tissue proteins as exemplified by the absence of antibody from the globin
of an immunized animal. /. Immunol., 1920, 5, 417.

By means of Schulz's method the authors prepared solutions of globin
from the haemoglobin of guinea-pigs and some other animals, and by
injection into rabbits claim to have produced antisera which can be demon-
strated by complement-fixation methods. Apparentl3^ success is obtained
only in the case of certain individual animals, and this may explain the
negative results obtained by Schmidt, and by Gay and Robertson. Positive
complement-fixation results depend on suitable quantitative relationships
between antigen and antibody,, as also upon a suitable hydrogen-ion con-
centration. The reactions with the antisera show in certain cases that
there is a marked species-specificity, for if one reckon the amount of com-
plement fixed by guinea-pig globin in the presence of the homologous serum
as 100 per cent., rabbit globin fixed 16 per cent, of complement, and ox
globin less than 6 per cent. On the other hand, anti-ox globin, fixes com-
plement in the presence of goat, duck, and guinea-pig globin, but not when
rabbit globin is the antigen used. The authors believe that the antibody is
a genuine antiglobin and is not due to any adventitious protein contamina-
tion during the preparation of the globin antigen. In a note they describe
the result of an experiment in which a rabbit was immunized with red
corpuscles of the ox until its serum was powerfully haemolytic. Blood
having been drawn from this immunized rabbit, an extract of its globin
was prepared, but although used in strong concentration produced no
haemolysis of ox corpuscles. W. B.

Matsumoto, Motomatsu. Experiments upon the production of anti-
human haemolysin with special reference to immunization with erythro-
cytes sensitized with heated serum. /. Immunol., 1920, 5, 507.

The difficulty of producing high grade antihuman haemolytic sera by
the immunization of rabbits with human red blood corpuscles is known to
all immunizators. The injurious effects of the inoculations have been
ascribed to anaphylaxis, direct "toxicity of the antigen, or to fatal embolism
due to agglutination of the red cells introduced. The most recent work
tends to eliminate the view that the phenomena are anaphylactic. The
present author confirms the statement of Vedder that exposure of human
erythrocytes to antihuman serum, diluted 1:10 and heated to 70°-80°C.,
reduces the susceptibility to haemagglutinin formation which otherwise

IV. N

166 ABSTRACTS

may cause injury or death of the animal. Solutions of human erythrocytes
in distilled water and largely freed of shadow corpuscles are much less
toxic and are better tolerated than suspensions of whole cells, and although
the yield of haemolysin may be slightly less are to be preferred as antigens.

W. B.

Fabdi, TJ. Sopra I'azione di sieri concentrati. [On the action of con-
centrated sera.] FatJiologica, 1912, 12, 388.

Concentrated serum of guinea-pigs is, within certain limits, innocuous
if injected intravenously in other animals of the same species ; but it is
fatal, even in small doses, if injected subdurally. Concentrated serum of
dog has the same effect if injected subdurally into guinea-pigs. This fatal
action of the subdural injections is attributed by the author to the con-
centration of the colloids of the serum, these probably having a direct
influence on important nerve centres. C. d. F.

FoiTTiCACCZA, L. Ricerche sperimentali sull' azione emolitica ed anemizzante
deir acido oleico e delle trioleine nei conigli. [Experimental investigations
on the haemolytic action of oleic acid and trioleins in rabbits.] Speri-
mentale. Arch, di biol., 1920, 74, 35.

Oleic acid has a remarkable haemolytic action in vitro, as well as
in vivo, this, however, being very much checked by the reaction of the
healthy organism if, of course, the acid is not put in direct contact with
the circulating blood. The reaction of the organism consists, first of all, in
a local inflammatory process by means of which the injected mass becomes
circumscribed from the surrounding tissues and only little of it can pass
very slowly into the blood-stream. There is, in the second place, a forma-
tion of more resistant erythrocytes as can be proved by testing them with
hypotonic solutions of NaCl. Lastly, there is a production of specific anti-
haemolysins, these having very likely an extrasplenic origin. Rabbits
treated with subcutaneous injections of oleic acid show only a form of
simple anaemia which j^gv se is not fatal and has none of the characteristics
of the progressive pernicious form. The lesions caused in the digestive
organs by the same treatment are also very slight and not at all similar to
those seen in progressive pernicious anaemia.

Ordinary oils (trioleins of olive, cotton, and linseed) may cause a very
slight anaemia in rabbits if administered ^je?' os in large quantities and for
a long time. This slight anaemia appears to be due, not to a possible
haemolytic action of the oleic acid freed from its glycerol, but to digestive
troubles, and to a diminished absorption of nourishing materials caused by
the great mass of oil occupying the enteric tube. By the administration of
varying doses of oils it has been impossible to cause in rabbits any change
similar to those of the progressive pernicious anaemia. The anatomical
lesions observed are simply those to be expected after the forced and repeated
introduction into the gastro-enteric tube of large quantities of fats.

C. d. F.

Hii.1., 1., and McQueem", J. M. The measurement of capillary blood-
pressure in man. Brit. J. Expcr. Path., 1921, 2, 1.

That pressure which stops the flow through and expresses blood from
the skin has been generally taken as signifying the capillary blood-pressure.

PATHOLOGY AND BACTERIOLOGY 167

In truth it indicates the pressure in the small arteries which feed the com-
pressed part after an allowance has been made for error arising from the
pressure required to deform the convex horny layer of the skin. The
method devised measures this error and arrives at the true pressure in the
small arteries. The pressure of a small jet of water is found which will just
blanch the skin of the hand held at heart level (1) in the normal condition,
and (2) with the capillaries at zero pressure after the veins of the forearm
have been emptied by gravity and the brachial artery occluded by a tourni-
quet. When (2) is deducted from (1) a reading of about 10 mm. Hg is
obtained. Reference is made to previous measurements of capillary pressure
in the brain, &c., and to recent experiments carried out on transparent
membranes of fi^ogs, mice, &c., by one of the authors (L. H.). These show
that a momentary compression equal to 2-5 cm. water suffices momentarily
to check the flow of corpuscles in the arterioles or their main capillary
branches. The true capillary pressure as indicated by these figures is a very
low one, and theories of lymph-formation, &c.; based on a capillary pressure
of some 30 mm. Hg must be modified accordingly. The relation of the
swelling of the tissue-cells to the capillary circulation in inflammation
is discussed, also the relation of the pressure of the cerebrospinal fluid,
aqueous humour, and salivary secretion. • P. F.

Azzi, A. Sul parallelismo fra reazioni vaso-motorie periferiche e polmonari.
[ Farallelism between peripheral and pulmonary vasomotor reactions.]
Sperimentale. Arch, di hiol., 1920, 74, 25.

Reference has already been made to the strict relations existing between
cutaneous and pulmonary vasomotor conditions (see Viale, G., Medical
Science, 1921, 3, 371). Azzi's investigations are much on the same lines
with this difl"erence, that he has made use of emotional and thermal stimuli
to cause peripheral vasomotor changes. These were registered by means of
Mosso's plethismograph, while the temperature of the expired air was
measured by means of a thermo-electric cell. The results obtained can be
summarized thus : There is a constant diminution in the temperature of the
expired air for every peripheral vasoconstriction, however caused.

C. d. F.

Nov ABO, P. Ricerche calorimetriche comparative sul digiuno e sull' avitami-
nosi. Nota III. [Calorimetric investigations on inanition and deficiency
disease. Note III.] Pathologica, 1920, 12, 183.

Reference has already been made to the investigations of this author
(Medical Science, 1921, 3, 372). She has now published an additional note,
in which the period of convalescence both from starvation and deficiency
disease are comparatively examined. The conclusions arrived at are :
(1) The temperature of the convalescent pigeons returns to 41° C. during
the first 24 hours, independently of the minimum reached during in-
anition or deficiency disease. Four or five days are then necessary for the
body temperature to reach the normal average of 42° C. (2) The amount of
heat given ofl", though greater tlian that of the last day of starvation
or deficiency disease, remains, in proportion to the body-surface, below the
normal average as long as the temperature has not become normal. After-
wards, it becomes greater than the normal average as long as the body-
weight has not also become normal. (3) With the exception of the first day

N 2

168 ABSTRACTS

of convalescence the animals take a quantity of food the energy value
of which may be even 50 per cent, above the normal average. This continues
until the body-weight becomes about the same as at the beginning of the
experiments. (4) The body-weight increases very rapidly in the first two
days of convalescence, the further increase being more gradual and rather
slow. However, the increase in body- weight is not always regular, but may
show various oscillations. (5) A strict relation appears to exist between the
various metabolic factors and variations in the body-weight. (6) All other
conditions being the same, the period of recovery lasts longer after deficiency
disease than after inanition. C. d. F.

Nov ABO, P. Sulle modificazioni del tessuto interstiziale in seguito a deficienza
di vitamina B nella dieta. [Changes in the interstitial tissue of the testicle
in consequence of deficiency in water-soluble accessory substance B.] Boll,
d. Accad. med. di Genova, 1920. (Pathologica, 1920, 12, 405.)

The testicles of four young pigeons, kept for two months on a diet of
polished rice, were examined histologically. Material was fixed partly
in Zenker and partly in Flemming. The testicular tubules were found
atrophic, and their epithelium degenerated in many places. The intertubular
spaces were larger than in normal specimens and filled with interstitial cells.
These, instead of appearing isolated or in small groups of two or three, were
arranged in well delimited rows supported by flattened connective tissue
elements. The interstitial cells had increased, not only in number, but also
in size, their nuclei being also larger than those of normal cells. In the
specimens fixed in Flemming's fluid the cj'^toplasm of such cells appeared filled
with many granules stained deeply black. The author comes to the con-
clusion that deficiency of the water-soluble accessory food factor B, causes
a true hypertrophy and hyperplasia of the so-called interstitial gland of the
testicle. C. d. F.

De Albebtzs, D. Su di un metodo rapido per la colorazione della nevroglia
fibrillare. [Quick process for staining neuroglia fibres.] Pathologica, 1920,
12, 240.

The process results from an original combination of the methods of
Weigert, Mallory, and L'h^rmitte, and is meant to be chiefly used for
•ascertaining quickly the possible existence of a proliferation of neuroglia
fibres in pathological specimens.

Sections are made by means of a freezing microtome from pieces fixed
in 15-20 per cent, formalin for about 24 hours, but no longer than three days.
They are collected in distilled water, transferred into a bath of 2 per cent,
acetic acid in 1 per cent, chromic acid (time not stated), washed for some
hours in repeatedly changed distilled water, oxidized for 10-15 minutes in
half per cent, potassium permanganate, washed again in distilled water,
reduced for 15-20 minutes in 1 per cent, oxalic acid, and, lastly, put to stain
for 12-24 hours in a saturated solution of Victoria blue. For the further
treatment, sections are washed in distilled water and from this lifted, one by
one, by means of a thin glass or platinum spatula, this to be also used
to plunge each section, for an instant, first into concentrated Lugol's
solution, then into absolute alcohol, and, lastly, into equal parts of xylol and
aniline oil, where the differentiation is accomplished in a few seconds.
Sections are finally collected and washed in slightly warmed and repeatedly

PATHOLOGY AND BACTERIOLOGY 169

changed xylol, and mounted in xylol-dainniar without a cover. Neuroglia
fibres are deep blue and red-blood corpuscles pale blue on an unstained
backgrounrl. ^- "• t .

Zappa, P. Contributo di osservazioni alia determinazione della formula leuco-
citaria normale. [On the normal leucocytic formula.] Pathologka, 1920,
12, 296.

In 1914 A. V. Bonsdorft" (Flnslca Idk-sdllsL handl., HeUliKjfors, 1914, 2,
1471), tried to show that if blood is regularly examined in the early hours
of the morning and before breakfast, the number of mononuclear leucocytes
is found to be almost the same as that of neutrophil polymorphonuclear
leucocytes, while the normal proportion established by Ehrlich and Einhorn,
and almost universally accepted as right, is of about 25 to 75. The author
of the present paper has taken advantage of a systematic series of examina-
tions carried out, during 1917, 1918, and 1919, on young and healthy subjects
(soldiers) with the object of controlling v. Bonsdortf's data, and of seeing how
far he was possibly right. It thus resulted that the normal nuniber of
mononuclears in proportion to the polynuclears in the leucocytic formula
should be considered higher than is generally believed. The proportion

between the former and the latter can be expressed by the fraction — j

, . , . . 1 r. .. 38 39 39-5 41-9 42 ,. ,,

which IS very near to the fractions w\' th' ^t^' ^^^"T' ^ representing the
•^ 62 bl 60-0 oo'i oo

values obtained by Jolly, Ostenfeld, Galambos, Turk (1912), Mehrthens, and

25
Bunting. All these values are higher than those given by Einhorn _, - •

95 26-9 31-7

Ehrlich and Lazarus '^- , Tiirk (1904) -— , v. Torday ^^ 5 Leredde,

S2'5 50*4

and Besancon — — , but still remarkably smaller than the fractions -r^—^
(j7'0 "^ 49-6

and j^ of V- Boiisdortf. C d. F.

Giuliani, R. Neutvalizzazione sessuale ottenuta mediante sieri orchilitici ed
ovariolitiei. [Sexual neutralization obtained by means of orchilytic and
ovariolytic sera.] Ann. d'ig., 1920, 30, 323.

Preliminary note on experiments made in rabbits by means of an
orchilytic serum oljtained by injecting nucleoproteid from rabbit's testis into
a sheep. The results, though very incomplete, are worth mentioning as they
show that it is perhaps possible to cause a total atrophy either of the testes
or of the ovaries by means of properly prepared sera — a problem of great
interest both from scientific and practical points of view. C. d. F.

PiSTOCCHi, G. L' influenza della milza, del rene, della tiroide nella produzione
della crisi anafilattica. [On the influence of the spleen, kidney, and thyroid
on the anaphylactic shock.] Pathologka, 1920, 12, 239.

Experiments were carried out on guinea-pigs, which had undergone
sensitization a few days after extirpation either of the spleen or of one

170 ABSTRACTS

kidney or of the thyroid. Splenectomy and nephrectomy had no influence
on the production of the anaphyhictic shock ; thj^roidectomy prevented the
latter in most of the animals on which the experiment had been performed.

C. d. F.

KuscA, C. I. Sul morbo di Gaucher. [On Gaucher's disease.] Atti d. Soc.
lonib. sc. med. e tiol., 1920, 9, 354.

Preliminary communication on exhaustive histopathological investiga-
tions carried out on the spleen, lymph glands, bone-marrow, thymus, and
solitary follicles of the intestine of a typical case of Gaucher's disease
observed in a baby of only eleven months. The characteristic Gaucher cell was
found in all organs examined, and the author consequently thinks that the
disease ought to be considered as affecting the whole haemo-lymphopoietic
system, tlie splenomegaly being only the chief clinical symptom.

C. d. F.

Samfietbo, G. Osservazioni sierodiagnostiche nel tifo petecchiale. [Sero-
diagnostic studies on typhus.] Ann. d'ig., 1920, 30, 593.

A series of careful investigations summarized by the author as follows :
(1) The Weil-Felix reaction was positive in 5*5 per cent, of the normal sera
examined, but with dilutions smaller than 1 : 100. It was also positive in
18 per cent, of the investigated sera of typhoid fever patients, but with dilu-
tions sometimes smaller, sometimes larger than 1 : 100. The reaction was
negative in cases of small-pox and other eruptive diseases. (2) In the sera
of cases of small-pox, agglutinins for B. ty2jJiosus may temporarily appear.
(3) The Weil-Felix reaction is positive in practically all cases of t3^phus, but
only from the end of the first week, if investigations are carried out with
dilutions not smaller than 1 : 100. (4) Agglutination curves for Proteus X 19
may be of three different types according to the length of time during whicli
agglutinins remain in the blood. This permanence is, in its turn, in direct
relation to the degree of concentration reached by the agglutinins themselves
in the patients' blood. They generally persist for about two months, but
were found even after four. (5) The agglutination curve may show a
sudden but quite temporary fall, particularly at the beginning or towards
the end of the curve. (6) The serum of typhus patients agglutinates
B. typhosus in 87 per cent, of the patients vaccinated against it, and
in 21 per cent, of the non- vaccinated patients. Widal's reaction may there-
fore be independent from antityphoid vaccination in typhus patients, but
the latter influences the results, increasing the percentage of positive cases.
(7) If both Widal and Weil-Felix reactions are positive, a serological dis-
crimination between typhoid fever and typhus can be attained only by
following the agglutination curves of both forms. (8) 63 per cent, of
the sera showing a positive Weil-Felix reaction also agglutinate a serological
type of B. ]yyocyaneus in dilutions even greater than those required to
agglutinate the Proteus X 19. As in the case of Proteus there are species of
B. pyocyaneiis which do not agglutinate. (9) As shown by Castellani's
test the agglutinins for B. pyocyaneus are independent of those for
Proteus X 19. By the same test the agglutinins for B. typhosus appear
sometimes as co-agglutinins, sometimes as independent agglutinins. (10) The
poly-agglutination of the serum of typhus patients is probably due to

PATHOLOGY AND BACTERIOLOGY 171

the mobilization of specific latent agglutinins produced during other, already
overcome, infections. (11) The Weltmann reaction is neither specific nor
constant; however, it may be useful for laboratory work. (12) TheWasser-
mann reaction, made with sera of typhus patients, has been attended by
negative results. C. d. F.

Naoao, K. The. fate of India ink injected into the blood. I. General
observations. '/. Infect. Bis., 1920, 27, 527.

The author lias made a careful examination of the tissues of rabbits and
guinea-pigs which had been injected intravenously with a suspension of very
Sne particles of Indian ink. For this purpose a stick of Indian ink was rul)bed
on an ink stone with a small quantity of 0-8 per cent, salt solution. The
suspension w^as then centrifugalized, and the upper part was filtered several
times through paper, the resulting fine suspension being then sterilized
discontinuously by steam. As a rule about 0-4 c.c. per kilo was the amount
injected. After injection the mucous membranes and spleen became black,
and this condition persists for some time. Ink granules are deposited
regularly in the endothelial cells of the liver, spleen, and marrow, and in the
splenocytes. Only a small number of granules were found in the adrenals,
kidneys, or lungs. In the spleen the granules were irregularly accumulated
at the periphery of or actually in the Malpighian corpuscles. Granules
were not found in the parenchyma cells of the nervous system. In the
blood, polymorphonuclear neutrophilic, and mononuclear cells, were found
to have taken up granules, but large lymphocytes did so only rarely.
Eosinophils and mast cells were not found with granules. Apparently,
ink granules were not discharged from the body by any particular organ.

W. B.

Pabbino, G. Ricerche sperimentali sulla fagocitosi. Sulla influenza che
spiegano sulla fagocitosi vari fissatori del protoplasma batterico. [Experi-
mental investigations on phagocytosis. Influence of various fixing agents. J
Sperimentale. Arch, di biol, 1920, 74, 76.

Di Macco, G. Ricerche sperimentali sulla fagocitosi. Modificazioni della
fagocitosi per effetto della fatica. [Experimental investigations on phago-
cytosis. Influence of fatigue.] Sperimentale. Arch, dihiol., 1920, 74, 81.

Caldebone, a. Ricerche sperimentali sulla fagocitosi. Modificazioni della
fagocitosi per I'azione di soluzioni diluite di acido cloridrico. [Experimental
investigation on phagocytosis. Influence of diluted solutions of hydro-
chloric acid.] Sperimentale. Arch, di biol., 1920, 74, 274.

These three papers form part of a series of systematic investiga-
tions on phagocytosis, carried out under the direction of V. Scaffidi at the
Institute of General Pathology of the University of Palermo.

Parrino has studied the influence on phagocytosis of various fixing
agents such as alcohol, formalin, corrosive sublimate, chromic acid, and
osmic acid. Investigations were carried out by a very exact method and
carefully controlled, Eberth's bacilli being used as test. It was found, that
while alcohol, formalin, and corrosive sublimate render Eberth's bacilli more
resistant to the phagocytic power of polymorphonuclear leucocytes, both
chromic and osmic acids have the opposite effect with a corresponding

172 ABSTRACTS

increase in the so-called phagocytic value. It is interesting to note that
this effect can be also obtained by means of corrosive sublimate if this
is re-dissolved after fixation by treating the bacilli with Lugol's solution.
This appears to indicate that the obstacle to phagocytosis is not always due
to the protoplasmic modifications caused by the fixing agents, but to the
combinations which these last form with the protein of the bacteria used as
tests.

Di Macco has studied the modifications in the phagocytic power of
polymorphonuclear leucocytes in guinea-pigs in the last stages of exhaustion,
a state brought about by means of a very simple apparatus which compelled
them to run at a known speed. The phagocytic index or value was deter-
mined for every animal before and after each experiment by the same
method and tests as used by Parrino. Di Macco comes to the conclusion
that acute fatigue causes a diminution of the phagocytic index, this being
reduced to about 25 per cent, of the normal value. This result agrees with
that arrived at by Ferranini and Fichera by means of a quite different
method. The diminution in the phagocytic index appears to be a direct
consequence of the influence of fatigue poisons on the various elements of
the blood. Three or four days are necessary for the phagocytic index
to again become normal, this fact pointing to the general conclusion that
fatigue poisons are only slowly destroyed or eliminated.

Calderone has investigated the influence of diluted solutions of hydro-
chloric acid made to act for various periods of time on Erberth's bacilli used
as test. Experiments were attended by unexpected results in that it clearly
appeared that the phagocytic value diminished when bacteria were kept in
contact with dilutions of HCl N/50-N/100 for some hours up to 24, but it
gradually increased when the contact was further prolonged. On the contrary,
when working with more diluted solutions as, for instance, N/800-N/l,000,
the opposite phenomenon was noticed, the phagocytic index showing an
increase in the first two hours and a diminution in the subsequent periods
of time. The diminution of the phagocytic index in the first hours of con-
tact of bacteria with little diluted solutions of HCl can be explained, assuming
that the chloro-protein which becomes thus formed has a negative chemo-
tactic power on polymorphonuclear leucocytes. The subsequent increase
under the same experimental conditions is very likely due to deep changes
in the bacterial protoplasm owing to the prolonged influence of the HCl. As
a mattei- of fact, there is a certain coincidence of time between the increase
of the phagocytic index and the death of the bacteria experimented upon.
But the transitory increase of the phagocytic index at the beginning of
experiments made with very diluted solutions of HCl remains entirely
inexplicable. The author can only point out that a similar fact was
observed by Oker-Blom (Ztschr. f. Immunitdtsforsch. u. ex'per. Therap., 1912,
Orig, 14, 485) when treating staphylococci with N/l,000-N/2,000 dilutions
of sulphuric acid.

In conclusion, phagocytosis is influenced not only by the biological
activity of bacteria iDut also by changes caused in them by the substances
with which they come in contact and by the length of time during which
this contact is prolonged. C. d. F.

BIOCHEMISTRY 173

BIOCHEMISTRY

Peters, J. P. (Jr.), and Barb, D. P. The carbon dioxide dissociation
curve and the arterial and venous carbon dioxide tension of human blood
in health and in disease. Froc. Soc. Exper. Biol. 4' Med., 1920, 18, 5.

A method for the direct determination of the carbon dioxide tension of
human arterial and venous blood has been applied to the examination of 23
subjects on whom 38 observations have been made. The method is similar
to that of Means, Bock, and Woodwell (Trans. Am. Assoc. Fhysiciaiis, 1920).
The group consisted of 3 normal persons, 6 with severe anaemia, 4 with
diabetes, 2 with emphysema, 1 with polycythaemia, and 1 with chronic
nephritis. The alveolar carlDon dioxide tension was also determined in
some cases.

In three cases of cardiac decompensation the dissociation curves lay
below the normal limits indicating a real reduction in available alkali. The
carbon dioxide capacity of the venous plasma was normal. In these cases,
therefore, the latter method is inapplicable as a measure of the available
alkali of the blood.

The dissociation curve in severe anaemia is more nearly horizontal, and
lies at a higher level than does the normal dissociation curve at carbon dioxide
tensions that exist in the body. This is due to the diminution in haemo-
globin which has the power of combining with a part of the alkali of the
blood. In cardiac dyspnoea the ditference between alveolar and arterial
CO2 tension was always much greater than normal, varying from 13-19 mm.
Hg. This indicates some impairment of the mechanism for the elimination
of carbon dioxide from the lungs. C. G. L. W.

Hendbix, B. M., and Cbouter, C. Y. Relation of the alkali reserve of the
blood to glycosuria and hyperglycaemia in pancreatic diabetes. J' Biol
Chem., 1920, 45, 51.

The results are against Murlin and Sweet's view of the causal relation
between the acid of the gastric juice and pancreatic diabetes. In dogs
from whom the pancreas had baen removed the decrease in alkali reserve
of the blood appeared considerably later than the hyperglycaemia and
glycosuria, thereby indicating that it was not a neutralizing function of
the pancreas that was at fault. B,. A. P.

Palmer, W. W., Salvesen, H., and Jackson, H. Relationship between
the plasma bicarbonate and urinary acidity following the administration
of sodium bicarbonate. /. Biol. Chem., 1920, 45, 101.

By the method of the authors, the grade of acidosis can be measured in
a subject by administering 2 grm. of sodium bicarbonate in 100 c.c. of water
every half-hour, immediately preceding the dose by a test of the reaction
of the urine. The ' first significant change in the urinary acidity ' is taken
as the end point, and the amount of alkali taken to produce this change
measures the acidosis. In severe cases more than 2 grm. sodium bicarbonate
is given at each dose. In normal and pathological cases, the plasma bicar-
bonate CO^ during this process approaches 68-7 ± 10 volumes of COg at the

174 ABSTRACTS

time that the first depression of the urinary acidity is noted. There appears
to be no close connexion between the function of regulating the acid-base
equilibrium possessed by the kidney and its ability to excrete phenol
sulphonephthalein. R. A. P.

SuNDSTROEM, E. S., and B1.0OB, W. R. Physiological effects of short

exposures to low pressure. J. Biol. C/iem., 1920, 45, 153.

B1.00R, W. R. Blood phosphates in the lipaemia produced by acute ex-
perimental anaemia in rabbits. /. Biol Cheni., 1920, 45, 171.

In the first paper, the authors have found that exposure of rabbits to
low atmospheric pressures causes a decrease in size in addition to an increase
in the number of erythrocytes. The phosphorus content of the red cells
does not change, though there is a decrease in organic phosphorus in the
plasma. There is a constant decrease in the lipoid phosphorus (lecithin) of
the plasma, which is considered to be connected with an enrichment of the
organs forming red blood corpuscles. Further, they think this decrease to
have some connexion with the stimulation of these organs by the low
atmosj^heric pressure.

In the second paper, the author has studied the distribution of lipoid
phosphorus (the lecithin fraction) during the lipaemia produced by bleeding-
rabbits. His idea is to find out more about the function of the lecithins in
metabolism, which are considered to bear an important part in the inter-
mediary metabolism of fat. He finds that of all the phosphorus compounds
in the blood, the lipoid phosphorus is most markedly afi'ected by bleeding,
being increased up to five times the normal in the plasma. This is accom-
panied by an increase in inorganic phosphorus, l)ut no change in the other
forms of phosphorus, so that the inorganic phosphorus and lipoid phosphorus
seem to be directly related to one another. R. A. P.

Haggard, H. W., and Henderson, Yandei.1.. Haemato-respiratory func-
tions. IX. An irreversible alteration of the H0CO3 NaHCO;; equilibrium
of the blood induced by temporary exposure to a low tension of COo. J.
Biol Chem., 1920, 45, 209.

This is one of a series of four papers in the number of the Journal by
the authors. In this paper, they show that the exposure of blood to a
tension of CO^ below a critical level causes the production of an irreversible
change. After such an exposure the blood will not combine with as much
CO^, as normally, upon re-exposure to the normal COo tension. Defibrinated
blood shows this change more readily than oxalated blood. It is partly
associated with bursting of the corpuscles, but there are other factors at
work. (Possibly one of these is the development of lactic acid in standing-
blood recently described by Mellanby and Thomas.) R. A. P.

Straub, H., u. Meier, Ei.othii.de. Blutgasanalysen. VIII. Der Einfluss
einiger Digitaliskorper auf die lonendurchgiingigkeit menschlicher Erythrocyten.
[Blood gas studies. VIII. The influence of certain digitalis bodies on the
permeability to ions of human red blood corpuscles.] Biochem. Ztschr., 1920,
111, 67.

This is the eighth of a series of studies on the permeability changes of
red corpuscles. The authors have found that the red corpuscles are im-

BIOCHEMISTRY 175

permeable to electrolytes in weakly l)asic solutions. As the acidity of the
solution, in wliich the corpuscles are suspended, is raised, there becomes
a sudden sharp!}' detined point at which the corpuscles become permeable.
The effect upon the inside of the cell is to allow the combination of acid
ions with the haemoglobin enclosed in the cell. Other ions besides the
hydrogen ion (acidity) influence permeability. The addition of potassium
to tile suspension fluid, for instance, makes the corpuscles permealjle at
a lower hydrogen-ion concentration (less acid reaction). This eflect can be
antagonized by calcium. The authors have interpreted their results in the
sense that there is a change of condition of the cell surface by adsorption of
the active ion. They, however, consider it misleading to picture a flne
extracellular membi-ane as the aflfected layer. Their results can be inter-
preted rather as a change of state of the whole cell protoplasm.

As they were struck with the general correspondence between these
permeability experiments and experiments upon the action of digitalis on
the heart, the authors have tried the eflect of adding digitalis to their blood-
corpuscle suspensions. They found that digitalis had the eflect of making
tlie corpuscles become permeable at a more acid point than the normal in
sodium chloride solution, thus resembling the effect of calcium ions. Potas-
sium ions antagonized tlie eflect. The result agrees with the pharmacoloc-ical
observation of the correspondence between the calcium and the digitalis
eflfect. R. A. P.

LiNZENMEZEB, G. Untersuchungen tiber die Senkungsgeschvvindigkeit der
roten Blutkorperchen. II. [Investigations on the rate of sedimentation of
the red blood corpuscles. II.J Arch. f. d. ges. Physiol, 1921, 186, 272.

As in the blood in pregnancy, so also in the ])lood of various animals,
sedimentation is retarded by shaking the plasma with kaolin, or by
heating to 56° C, and is hastened by gelatin or gum. The sedimentation
(which is due to the removal of the negative charge on the corpuscles) is
also hastened by fibrinogen, histone, or protamine, but not by albumin,
nuclein, sodium nucleinate, or peptone. The sedimenting factor in blood is
probably not fibrinogen, but a definite fraction of the globulin. The bloods
of different species show individual peculiarities in the sedimentation, which
seems to be related not only to the alteration of the electric charge, but
also to an adsorption of the agglutinating substances on the surface of the
corpuscles. C. L. E.

Abdebhaldem", E. Die Beziehungen der Senkungsgeschvvindigkeit der roten
Blutkorperclien zu ini Plasma vorhandenen diaylsierbaren Verbindungen ; Bezie-
hungen zu den Abvvehrfermenten. [The rate of deposition of erythrocytes
in plasma and its relation to protective ferments.] Fermentforschung, 1921,
4, 230.

It has been known for some time that the corpuscles in the blood
of pregnant women settle more rapidly than normal blood. Abderhalden
has attempted to bring this phenomenon into relation with his much
discussed pregnancy test. Linzenmeier's results showed that the change in
rate of deposition occurred in those cases where the pregnancy test was
positive. Abderhalden shows in the present paper that there are sub-
stances present in gravid blood which will cause normal corpuscles to sink

176 ABSTRACTS

more rapidly, and these substances may be removed by dialysis of the
plasma. The plasma obtained from the umbilical cord does not behave like
the maternal plasma. Certain peptones and amino-acids were examined
for their influence on settling. No effect was made out. C. G. L. W.

CouiiTEB, C. B. The isoelectric point of red blood cells and its relation
to agglutination. J. Gen. Physiol., 1921, 3, 309.

The H-ion concentration at which red corpuscles have no electric charge
is at Ph = 4'6. On the alkaline side of this, they are negative ; on the acid
side, positive. The charge carried by sensitized cells on the alkaline side is
smaller than that of normal cells. On the acid side, both kinds of cells
' combine ' with H and CI ions ; on the alkaline side with cations. The
optimum for agglutination of normal cells is at Ph = 4-75; for sensitized
cells, at Ph=5-3. The latter value is related to the optimum for flocculation
of the immune body. W. M. B.

VosscHUTZ, J. Untersuchung iiber Agglutination und Sedimentierung von
Bakterien. [Investigation on the agglutination and sedimentation of
bacteria.] Arch. f. d. ges. Physiol, 1921, 186, 290.

Certain bacteria, but not all, are agglutinated by the serum of pregnant
women under the same conditions as are red blood corpuscles. It is inferred
that the fundamental physico-chemical phenomena are also similar, viz.
that sedimentation is preceded by the removal of the electric charge on the
organisms in suspension. C. L. E.

Hess, A. F., and TTngeb, L. J. Dietaries of infants in relation to the
development of rickets. Proc. Soc. Exper. Biol. 6,- Med., 1920, 17, 220.

In an examination of infants on various diets, which were continued
for six months, it was found that many diets supposed to be conducive to
rickets resulted in normal nutrition. Condensed milk only occasionally
produced rickets. The one food which regularly caused the condition was
' protein milk ' prepared by precipitating buttermilk with heat (not with
rennin). This preparation contained 3-3 per cent, of protein, 25 per cent, of
fat, and 6-6 per cent, of carbohydrate. Its ash was about 0-44 per cent., of
which the phosphorus and calcium content stood midway between human
and cows' milk. The fat-soluble vitamine content was high, the water-
soluble vitamine low. This diet must be regarded as one markedly pro-
ductive of rickets. All the infants received an adequate supply of orange
juice during the period of feeding. C. G. L. W.

McCoi.i.uM, E. v., SxMMOHss, N., Parsons, H. T., Shipley, F. G., and
Fabk, E. a. Studies on experimental rickets. I. The production of
rachitis and similar diseases in the rat by deficient diets. II. The effect
of cod-liver oil administered to rats with experimental rickets. J. Biol.
Chem., 1921, 45, 333 and 343.

These interesting papers form, so the authors say, the beginning of a
series. By uniting the interest of the Chemical Hygiene Department and
the Department of Pediatrics of Johns Hopkins University, it has been
possible to initiate an intensive study of the dietary and patliological sides
of rickets in rats.

1 1

BIOCHEMISTRY 177

Diets faulty cither in calcium or fat-soluble A especially, or deficient
in certain other ways, have been found to induce disturl)ances in the growth
of the skeleton such as fractures, enlargement and distortions of the costo-
chondral junctions, vertebral deformity, irregularities in the calcification of
the intercellular substance of the proliferative cartilage. The authors lay
stress upon the difficulty at this stage of drawing conclusions, though it is
interestnior that calcium and fat-soluble vitamine seem to be the most
prominent factors. In the second paper of tlie series, a preliminary one,
they claim that the feeding of cod-liver oil to rats suffering from lack of
fat-soluble vitamine induces the deposition of calcium salts between the
cells of the proliferative zone of cartilage. This line suggests a means by
which cod-liver oil produces its effects in the treatment of rickets. (It is
surprising that the work of E. Mellanby should not be mentioned by the
authors). R. A. P.

DuTiKER, B. A., £cKi:.ES, C. H., Dahle, C. H., Mead, S. W.,and Schaefeb,
O. G. Vitamine studies. VI. The influence of diet of the cow upon the
nutritive and antiscorbutic properties of cow's milk. J. Biol. Ghem., 1020,
45, 119.

The vitamine content of cow's milk is dependent upon the vitamine
content of the ration ingested by the cow. 20 c.c. of summer milk were
superior to 60 c.c. of winter milk in antiscorbutic potency and nutritive
value. Milk becomes poor in vitamine slowly, but the vitamine is quickly
restored when the animal is fed on a vitamine rich diet. R. A. P.

OsBOBNE, T. B., and Mendei., L. B. A critique of experiments with diets
free from fat-soluble vitamine. J. Biol. Chem., 1921, 45, 277.

•)

The authors draw attention to the contradictions existing in the
literature as to the presence or absence of fat-soluble vitamine in a given
experimental diet. They instance some results of Daniels and Loughlin in
which the conclusion was drawn that rats could be made to grow, reproduce
and rear their young upon a diet ' in which the only apparent source of
vitamine was lard or cotton-seed oil '. Other workers have concluded that
lard is not a source of fat-soluble vitamine. In many experiments it has
been found that in the apparent absence of a supply of fat-soluble vitamine,
animals will grow quite well for a time before failure. Results of this
kind have been attributed either to ' exceptional vitality ' or to a possession
of a reserve store of vitamine in the body. By extracting carefully the
other constituents of the diet, viz., proteins and carbohydrates, the authors
have been able to diminish to some extent the period of unrestricted growth
upon diets deficient in fat-soluble vitamine. They are inclined to think
that the discordant results of various workers may perhaps be due to traces
of fat-soluble vitamine adhering to proteins, &c., in the diet. However,
they point to the fact that the crucial experiment in which nutritive
failure ensues immediately upon giving a diet deficient in this respect has
not yet been done. R. A. P.

OsBOBNE, T. B., and Mendei., L. B. Growth on diets poor in true fats.
J. Biol. Chem., 1920, 45, 145.

Rats fed on a diet in which the largest fat intake daily per animal was
not more than 0078 ptui. o-rew well. This indicates that if ' true fats
are essential for nutrition during growth, the minimum requn-ed must be

178 ABSTRACTS

exceedingly small '. In all cases, a source of fat soluble vitamine was
added. R. A. P.

Drummond, J. C. Nutrition on diets practically devoid of fat. J. Physiol.,
1920, 54, XXX.

The accessory food factor A (fat-soluble A), was supplied by an
alcoholic extract of fresh carrots containing only the smallest traces of
neutral fat. The basal ration was composed of caseinogen and starch (both
extracted with alcohol and ether), inorganic salts, orange juice and yeast
extract. To this a daily ration of 5 c.c. of the concentrated carrot extract
was added. The approximate daily intake of neutral fat was 14 milli-
grammes. Young rats remained in good health on this diet for nearly
six months, and showed considerable, though, on the whole subnormal,
growth. O. L. V. de W.

WiTZEMAiTiT, E. J. Disodiumphosphate as a catalyst for the quantitative
oxidation of glucose to carbon dioxide with hydrogen peroxide. J. Biol.
Chem., 1920, 45, 1.

This paper is of considerable interest in connexion with carbohydrate
metabolism. The author has confirmed and extended some results of Lob.
The latter showed that in the presence of phosphates glucose was oxidized
by hydrogen peroxide to CO^ and H.^O. The author has found that, at the
temperature reaction of the body, glucose is oxidized in the presence of
disodium phosphate by hydrogen peroxide, the phosphate apparently acting
as a catalyst. Compounds of hexoses and phosphate (hexose-phosphate) have
been described by Harden and Young, Neuberg, and others, in connexion
with the fermentation of yeast, and also with the precursors of lactic acid in
the muscle. Thinking that a hexose-phosphate might be playing an inter-
mediate part, the author tried to isolate such a compound, without success.

R. A. P.

CusHiirCr, H., and Foley, F. E. B. Alteration of intracranial tension by
salt solution in the alimentary canal. Proc. Soc. Exper. Biol. ^" Med., 1920,

17, 217.

Weed and McKibbon (Am. J. Physiol., 1919, 48, 531) have shown
that it is possible to reduce the cerebrospinal fluid pressure, and diminish
the bulk of the brain by injecting a hypertonic salt solution into the blood-
stream. Hypotonic solution had the opposite effect. Cushing and Foley
have confirmed these results and have attempted to achieve them in another
way. By introducing 20-30 c.c. of a saturated solution of sodium chloride
into the rectum or duodenum of a cat, a maximal fall of cerebrospinal
pressure was produced as if the solution were given intravenously. The experi-
ments were repeated with patients with brain tumours and cerebral herniae
subsequent to decompression operations. Occasionally very striking results
were obtained in which a tense convex protrusion became a soft concave
area over the decompression site. C. G. L. W.

ChefIiIN, H. a., and Kettger, L. F. Further studies on intestinal
implantation of Bacillus acidophilus. Proc. Soc. Exjjer. Biol. Sf Med., 1920,

18, 30.

The preparation of B. acidophilus milk is conducted by using mixed
strains of the bacillus wliich have been grown sufficiently long on milk to

BIOCHEMISTRY 179

bring about light curdling within 24 hours. If the milk is more or less
acid before sterilizing, the linal product is of an even consistency, granular
and lumpy.

Successfully prepared acidophilus milk is of uniform creamy con-
sistency. The odour is slightly aromatic. The acidity is always below 1-0
per cent. Samples of milk which have been kept at room temperature for
two weeks are practically indistinguishable from the fresh product. The
clinical results in eftecting a transformation of the flora of the intestine by
the use of the milk have been most promising. C. G. L. W.

Uhi.eii'HUTH, E. Experimental gigantism produced hj feeding pituitary
gland. Froc. Soc. Exper. Biol. ^- MecL, 1920, 18, 11.

By feeding the anterior lobe to salamanders specimens were produced
which attained a growth much larger than any which have hitherto been
seen. If the animals are fed on the posterior lobe, growth may be greatly
retarded. Feeding produces both acceleration of growth and continuation
beyond the specific size of the species. C. G. L. W.

Cameron, A. T., and Carmichaei., J. Biochemistry of iodine. III. The
comparative effects of thyroid and iodide feeding on growth in white rats
and in rabbits. J. Biol. Ohcm., 1920, 45, 69.

The effect of feeding continued small doses of desiccated thyroid gland
to young wliite rats was threefold. There was a definite decrease in the
growth-rate, a hypertrophy of the heart, liver, kidneys, and adrenals, and
a disappearance of fat. The latter two results confirm those of Hoskins
and Herring. The decrease in rate of growth is proportional to the amount,
and also to the iodine content, of the thyroid tissue fed. The hypertrophy,
varying with the dose and length of duration of the feeding, is proportional
to the iodine content. The feeding of sodium iodide does not reproduce
these effects, nor does the extract of other glandular tissues. R. A. P.

Uhlenhuth, E. Experimental production of gigantism by feeding the
anterior lobe of the hypophysis. J. Gen. Physiol., 1921, 3, 347.

Metamorphosed salamanders (Amby stoma opaciiin and tirjrinum) grew
much more rapidly on anterior lobe of hypophysis than did controls on
earthworms. Experimental giants were produced. W. M. B.

Fezabd, a. Numerical law of regression of certain sex characters.
J. Gen. Bhysiol., 1921, 3, 271.

Post-puberal castration in cocks results in a regression of the comb
similar to that effected by castration 1 )efore puberty. The rate of diminution
is represented by a segment of a parabola. W. M. B.

ROKA, P., u. Petow, H. Giftwirkung des Thiodiglykols und seiner Derivate
an Sojabohnenurease. [Poisonous effect of thiodiglycol upon urease.] Bio-
chem. ZtscJir., 1920, 111. 134.

These experiments have some interest in connexion with the toxic effect

,ptj pw pi

of mustard gas. Mustard g-as, or dichlor-diethyl sulphide S< ^ ^

^ ^ \CH,-CH,C1

is (as has been demonstrated recently), very toxic in its effects, whereas

180 ABSTRACTS

/CH2CH2OH . ,. 11 , . rru •

tliiodio'lvcol Sx IS practically not poisonous. Ihe curious

"^^ \CH,CH.30H

fact is that the former substance in water rapidly passes into the latter
with splitting off of CI. It has always been difficult to relate the toxic effect
of the chlorine derivative in the body to its chemistry. The authors here
have found an analogy in the effect of the two substances upon the ferment
urease. This ferment splits urea to ammonia and CO.^. Thiodiglycol does
not poison the ferment, whereas dichlorethyl sulphide stops the action of
urease even when used in quite small quantities. R. A. P.

BIBEBFEZ.D, J. Zur Kenntnis der Gewohnung. IV. tJber Gewohnung an
Kodeinderivative (Eukodal u. Parakodin). [On acclimatization to drugs.
The acclimatization to codein derivatives (eucodal and paracodein).] Bio-
cJiem. Ztschr., 1920, 111, 91.

The author concludes that eucodal depresses the respiration more than
morphin, though the former is less poisonous than heroin.

Rabbits do not get accustomed to doses of eucodal. In dogs the seda-
tive effect soon wears off by repeated injection, and is replaced by an
excitant effect for larger doses. Paracodein has a stronger effect upon
respiration than codein, weaker than eucodal and morphin ; dogs show an
acclimatization to the sedative component of the effect. R. A. P.

VAN DEB WiLLiGEN, A. M. M. Die Abfiihrwirkung des Schwefels. Die
Abflihrwirkung des Kalomels. Die Abfuhrwirkung des Phenolphthaleins.
[The purgative action of sulphur— of calomel —of phenolphthalein.] Arch.
/. d. ges. Physiol., 1921, 186, 173, 185, 193.

Experiments were made on cats, by the bismuth meal and X-ray
method, before and after the administration of the various cathartics.
Some experiments were also made on isolated loops of intestine. The action
of sulphur was shown to be due to the effect of sulphuretted hydrogen pro-
duced from it in the large intestine (and passed in the flatus). The move-
ments of the proximal colon are so accelerated by the sulphuretted hydrogen
that the normal absorption of water in that portion of the bowel is much
reduced. No sulphuretted hydrogen was detected in either the expired air
or blood after administration of sulphur. The absorptive and secretory
activities of the intestinal mucosa were unaltered. Calomel hastens the
passage along both small and large intestines, and likewise leaves secretion
and absorption unaffected.

Phenolphthalein chiefly stimulates the colon, and to a much smaller
extent the small intestine, and does not affect either secretion or absorption.

C. L. E.

SCHUZ.Z, W. Der Verlauf der Kreatininausscheidung im Harn des Menschen
mit besonderer Berucksichtigung des Einflusses der Muskelarbeit. [The course
of creatinin excretion in the urine in man, with especial reference to the
effect of exercise.] ArcK f. d. ges. Physiol., 1921, 186, 126.

The daily creatinin excretion is moderately constant on a creatin-free
diet, and is independent of the volume of urine passed. It falls steadily
during starvation. During the day there are three maxima, at about

BIOCHEMISTRY 181

10 a.m., ^-4 p.m., and 8-10 p.m., and these are unaltered in starvation.
Creatin is absent except during starvation. During muscular exercise,
whether in the fed or fasting subject, there is a rise in the creatinin output,
but the daily excretion is unaffected. G. L. E,

RADIOLOGY

Radio-technique

Taylor Jones, E. The action of induction coils. J. Hunt. Soc, 1920,
16, 47.

The paper deals mainly with variations in the wave-form of potential
at 'break ', consequent on tlie variation of the frequency-ratio of an induc-
tion coil. The first part of the paper is based on the theory that when the
secondary terminals are insulated the wave-form of potential after ' break '
consists of two components which begin in opposite phase and the initial
amplitudes of which are inversely proportional to their frequency. The
author shows that the maximum potential cannot exceed the sum of the
amplitudes and can only attain this value for frequency-ratios 3, 7,
11, &c.

The frequency-ratio of a coil is smallest when the primary capacity is
such that L^C^ = L.^G.2, its value then depending on the coupling. For still
smaller values of the primary capacity the frequency -ratio steadily increases,
and it is to this range that the author restricts himself.

By withdrawing the primary and core to various distances along the
axis of the secondary and consequently altering the coupling, it was found
that the spark length produced at the interruption of a given primary
current was a maximum when the primary was about 1 foot from its
normal position. The coupling was found to be 0-58 for this position of the
primary coil. The experimental curve, showing the way in which the
secondary potential varies with the primary capacity, is well in accord with
theory except that the potential is reduced considerably by the damping.
In actual coils the least efficient coupling appears to be rather smaller than
the corresponding value for a coil devoid of damping. The author's experi-
ments show that the spark length for an 18-inch coil does not necessarily
increase with the mutual inductance, and that the effect of damping in
reducing the secondary potential increases with the coupling, amounting
in some cases to a 25 per cent, reduction.

A description is given of an electrostatic oscillograph capable of being
used up to 200,000 volts, and some examples of the photographs obtained
with it illustrate remarkable agreement between theory and experiment.
Other wave-forms, obtained when the oscillograph was connected to the
terminals of a fairly soft X-ray tube, suggest that the latter is behaving
like a resistance which, while greater than that of a spark of moderate
length, is still sufficiently small to be non-oscillatory. A hard tube follows
more closely the nominal form when the terminals of the coil are insulated.

L. H. C.

IV. o

182 ABSTRACTS

FKZI.I.ZFS, C. E. S. A suggested new method of measuring X-ray dosage.

Arch Radiol 4- Eledroth., 1920, 25, 215.

The main feature of the suggested ionization method is the use of
a thermionic valve which enables small variations of current in an ioniza-
tion chamber to be transformed ' up ' to give corresponding variations of
a much larger current in a separate circuit at low tension. The recording
instrument is a milliampere-meter which is included in the separate circuit.

The ionization chamber is hermetically sealed and has two, parallel
plate, electrodes, the lower resting in a bed of ebonite and* connected by
a short, heavily insulated wire to the grid of the valve.

The author describes the action of the thermionic valve and states that
the recording instrument should give steady readings, which will vary with
the intensity of radiation. L. H. C.

Radio-diagnosis

Daztdt, W. E. Localization or elimination of cerebral tumoiu's by ventri-
culography. Surg. Gyncc. 6f Obst, 1920, 30, 329. (■/. de radiol. et d'electrol,
1920, 11, 520.)

It is very difficult to localize cerebral tumours clinically unless they
are large, but it is only by exact localization that they can be removed.
Radiography of the ventricles consists in passing into one of the lateral
ventricles a needle through which air is injected after the removal of some
of the cerebrospinal fluid, after a preliminary small trephining under a
local anaesthetic. A series of X-ray photographs is then taken from
different positions in such a manner that the various parts of the ventricle
in turn may contain the air. Every cerebral tumour alters the shape of
the ventricle. By this method an early diagnosis, and therefore an early
removal, of the tumour can be made. P. L.-B.

DuvAii, P., Roux, et BscitiiBE, H. L'ulcere de la petite courbure de restomac.
[Ulcer of the smaller curvature of the stomach.] Arch, dielectric, med., 1920,
28, 289.

An ulcer of the lesser curvature presenting Mathieu's syndrome can
be definitely diagnosed by X-rays.

(1) Under the X-rays there are two modifications of the lesser curva-
ture : («) a portion of the lesser curvature becomes straight ; (6) a diverti-
culum of Haudek. The straight portion varies in extent, but is always at
the periphery of the ulcer and corresponds to the point which is painful on
palpation. A typical diverticulum of Haudek indicates an ulcer which has
invaded the perigastric tissues.

(2) Modifications of the larger curvature consist of an indentation in
the wall and sometimes in a mixed biloculation. The indentation always
occurs in the same place ; its usual position is opposite the ulcer. It may
be the only sign of an ulcer, DifTerential diagnosis between this and
functional or cicatricial contractions is given.

(3) The general appearance of the stomach is modified in several ways.
The action of the pylorus should be closely examined. The author classi-
fies the X-ray appearances of the ulcers thus : (a) commencing ulcer ;

RADI0L(3GY 183

(b) definite ulcer without perforation or contraction ; (c) punched out ulcer
with projecting edges ; {d) ulcer with mixed biloculation. The signs of
these various types are given. It is stated that radiology alone is in-
sufficient, but combined with clinical observation is of the greatest value.
An X-ray photograph is not enough ; examination under the screen must be
undertaken and the radiologist and physician or surgeon must collaborate.

P. L.-B.

Sfbigos, E. I. Duodenal divertictda. Brit. J. Surg., 1920, 8, 18.

In a thousand consecutive X-ray examinations of the alimentary tract,
duodenal diverticula have been seen ten times ; they rarely gave rise to
symptoms. The shadows may cause confusion unless their nature is realized
and the contents are seen passing into the duodenum. The size varies from
a linseed to a hen's egg. The commonest situation is the second part of the
duodenum, of which the region of the ampulla of Vater is the favourite site.

P.L.-B.

Cols, L. G., and Roberts, D. Duodenal diverticula ; their clinical and
radiological aspect. Surg. Gynec. c|- Ohst., 1920, 31, 376. {Arch. (Velectric.
mcd., 1920, 28, 364.

Up to a few years ago diverticula of the intestine were scarcely recog-
nized. Those of the large intestine were the first and best studied, the rest
being looked upon as curiosities. Cole and Roberts show that duodenal
diverticula occur more frequently than w^as thought. They occur par-
ticularly in the region of the ampulla of Vater and develop there at the
expense of the posterior wall or of the lumen of the duodenum. Diverticula
of the first part are very rare, but less so than those of the third or fourth
parts. Single, or in groups of three or four, the size varies from that of
a nut to that of a pear : the opening is large or narrow, and the interior some-
times contains food debris.

Their presence entails certain symptoms and complications, such as
intestinal obstruction, persistent indigestion, regurgitations of food, which
may be haemorrhagic and chronic ; the authors also think that diverticula
are not unconnected with primary cancer of the duodenum, rare though

it be.

On radiological examination, the fact that the meal remains in these
pouches, reveals'^their presence : most often, however, the opaque meal only
confirms their presence and their anatomical grouping, whether round the
ampulla of Vater or not. The diagnosis, however, always remains very
delicate, because in the presence of shadows visible before an opaque meal
it will be necessary to bear in mind renal, biliary, and pancreatic calculi,
calcified mesenteric or retro-peritoneal glands, or faecal concretions. When
the opaque meal has been taken, it will be necessary to think of dilatation
of the first part of the duodenum accompanying a duodenal ulcer ; per-
forating ulcers ; fistulae between duodenum and gall-bladder ; further, it
must not be forgotten that, in a patient who has taken a bismuth or barium
meal, intestinal shadows due to particles of these substances can be seen for
several days.

Also, owing to the difticulty of such a diagnosis, one examination is not

184 ABSTRACTS

sufficient. Many should be made, and only after a very careful comparison
of the results has been made can the existence of a diverticulum be affirmed.

P. L.-B.

BiAMOND, P. Le spasme du pylore. [Pyloric spasm.] Presse med., 1920,
May. {Arch, dielectric, med., 1920, 28, 344.)

In its complete form spasm of the pylorus shows itself by the
followino- radiological signs : at the moment of its arrival in the stomach,
a part of the opaque meal passes into the duodenum by ' surprising ' the
pylorus. Contraction having taken place, the closed pylorus appears as
a light band, clearly seen above the horizontal plane, passing through the
fundus of the stomach. Above may be seen an immobile column of bismuth
with no tendency to empty itself either into the duodenum or into the
stomach. After a time, sudden relaxation of the sphincter supervenes, and
the bismuth mass is either forced precipitately into the duodenum, or passes
little by little. At the same time the duodenal column separates into two
portions, one part progresses towards the second part of the duodenum,
while a small amount of bismuth returns into the stomach. In a less
vigorous form of pyloric spasm, the pyloric region is always clearly visible,
but it allows a fine opaque thread to pass ; the duodenal column is not so
high, and the duration of the phenomenon is shorter.

It is possible to bring the spasm still better into relief : (1) by manual
compression of the pyloric region, with the object of forcing open the
sphincter, the resistance of the pylorus is more prolonged and sometimes
absolute ; (2) a spoonful of syrup of belladonna or an injection of 1 mg. of
atropin brings about cessation of the spasms (this test sometimes fails) ;
(3) a cachet of 50 cgrm. of adrenal ingested a quarter of an hour before
examination often reveals a latent spasm, or exaggerates it if it be already
in existence ; the patient experiences painful cramp and the screen shows
a good image of the spasm. S. U. L.-B.

HiNMAN, p. Diverticules vesicaux. [Diverticula of the bladder.] Surg.
Gynec. S,- Ohsf., 1919, August. {ArcJi. d'electrk. med., 1920, 28, 345.)

Cystoscopy and radiography have shown that vesical diverticula are
much more frequent than was believed, and from 21 personal observations
the author draws the followino: conclusions :

The largest proportion is furnished by men between the ages of 50 to
60 years ; women are nearly always exempt, the author only having observed
two cases.

Three different examinations are necessary to make an exact diagnosis
of this affection. The first by cystoscopy, the second by radioscopy, the
bladder having been previously filled with an opaque liquid, and the third
by radiography. As this last examination must serve to differentiate
between the vesical cavity and the diverticula and to indicate the seat of
the orifices which connect them with the bladder, it can only be made after
having emptied the vesical cavity and replaced its opaque contents with an
injection of air. In this way will be shown, in positive cases, a light mass
formed by the bladder, crossed by the shadow of the diverticula which still
contain the opaque liquid.

According to the author, a single diverticulum is most often found and

RADIOLOGY 185

in this case it borders on the ureteral orifice. In the case of multiple diver-
ticula they are seen at the base of the bladder and their volume is tlien less
than in the case of a single diverticulum. From the clinical point of view
the symptoms are va^^ue and dominated by the phenomena of prostatic
lesions which almost always accompany diverticula. Diagnosis can only be
made by cystoscopic and radioscopic examination. S. U. L.-B.

Radio-biology

Buss, S. Some problems in the biological action of radiations. J. Hunt.
Soc, 1920, 16, 134.

In treating, say a rapidly growing tumour, one of the greatest diffi-
culties in administering a lethal dose is that the cells are in different stages
of activity. It might be thought that a rapidly growing tumour would be
more vulnerable than one growing slowly, but this is not always the case:
the response also depends on the type of cell. If a tumour disappears after
radiation it may do so because of chemical or physical processes, but which
is the more important is not known.

In carrying out experiments in vivo and in vitro, the results may be
widely different or the same : experiments on lymphocytes after radiation
vary greatly iti vivo and in vitro, whereas those on Jensen's rat sarcoma
give almost identical results. The former may be an action on the exterior
of the cell and on its surrounding, while the latter is almost certainly on the
internal structure of the cell.

There may be two variables, («) the cell, and (h) the radiation. As yet
the energy of radiation from one part of the spectrum with that of another
cannot be compared.

The biological reaction of a tissue bears no simple relation to the
amount of energy absorbed when exposed to different parts of the spectrum.
It may be significant that the U. V., X-rays, and y-rays, which give the
most pronounced biological actions, are those which give rise to the most
marked electronic emission.

The electronic emission probably gives rise to physical rather than
chemical conditions, as chemical changes are only seen after heavy doses,
while numerous physical effects can be seen after small doses. Electrical
forces play a considerable part in many processes. It has been shown for
several types of cell that the same amount of energy from /3- and y-rays
will produce similar results. P. L.-B.

Bagg, H. J. The response of the animal organism to repeated injections
of an active deposit of radium emanation. Intravenous injections in dogs.
Am. J. Cancer Research, 1920, 5, 301.

The animals were two bitches, one a Dalmatian, the other a mongrel.
Complete urine analyses were made before and after treatment ; frequent
blood examinations were made, temperature and weight recorded, and histo-
logical examinations made of post-mortem specimens.

The active deposit consisted of a solution in which radium emanation
had been deposited on NaCl, which was later dissolved in sterile water to
make a physiological salt solution.

186 ABSTRACTS

The injections were made into the veins of the ear, about 2 e.c. being-
injected at a time. Tlie syringe was lead covered. A second injection was
not made until the metabolism had recovered.

Blood examinations were made from the ear. Temperatures taken in
the rectum.

Dog I. Experiments lasted for three months ; four injections were
made totalling 231-8 mc. The first injection was of 95'3 mc, after which
the animal was affected for two days ; the second injection a month later
was apparently without effect except for loss of appetite on the 13th, 23rd,
and 24th days.

After the first injection the leucocytes fell in number till tlie eleventh
day, from 10,250 to 4,200 ; from then onwards there was a steady recovery.
After the second injection the white cells again fell, but the red slightly
increased in numbers. On the eleventh day there was a marked decrease
in the polynuclears with a rise in the lymphocytes, but the differential
count was normal before the second injection. After the injection there
an increase in the total nitrogen and urea and a considerable increase in
the uric acid and phosphates in the urine.

The second injection was made on the thirty-first day ; the dose was
30 mc. The faeces became slightly fluid, otherwise the animal was normal.
The temperature was low and irregular for a few days. After 3 days the
leucocytes were slightly raised, but later fell to about 75 per cent. The red
cells fell slightly at first.

The third injection was made on the forty-second day ; the dose was
42 mc. There followed diarrhoea and loss of appetite for 10 days and the
animal lost 2 lb, in weight. The temperature rose sharply and was high and
irregular for several days. On the third day after injection the leucocytes
had fallen to 2,900 but increased to 12,500 before the next injection :
Hb. 80 per cent. The red cells increased in number to nearly a million more
than normal before the fourth injection. The blood clotted rapidly. The
urine contained an increase of total nitrogen, urea, uric acid, creatinin, and
total phosphates.

The fourth injection was made on the sixty-fifth day; the dose was
64-3 mc. It was followed by severe vomiting, constipation, and a sudden
rise of temperature to 102°. The animal refused food for two days and was
seriously ill ; there was a loss of weight of 3 a lb. The white cells fell to
5,600, the red cells fell slightly. There was a relative increase of lympho-
cytes and fall of polynuclears. The excretion of urine was increased.

Histologically there was an intensely congested liver with granular
degeneration. The kidneys were congested and showed degeneration of the
tubule cells. The Malpighian bodies of the spleen were prominent, few cells
in the pulp. The colon was congested. The lymph nodes were congested.
The lymph follicles decreased in size. No changes were noted in lungs,
stomach, small intestine, or thyroid.

Dog 11. Experiments lasted two months. Four injections were given
totalling 338-4 mc. The first injection was followed by a low and irregular
temperature for several days. Vomiting occurred after three days. The
animal refused food and lost 2 lb. in weight in six days. The leucocytes
fell from 14,400 to 2,150 in seven days. The red cells fell by nearly two
million, causing a fall of Hb. from 85 to 75 per cent. There was a large
increase of uric acid and total phosphates in the urine.

The second injection was made on the twenty-eighth day ; the dose was

RADIOLOGY 187

17*3 mc. After an initial fall, the temperature rose to 102*5° on the second
day. There was a decrease in the white cells, but the red cells increased
slightly in numbers. There was only a slight increase in the total nitrogen,
uric acid, &c.

The third injection was made on the thirty-seventh day ; the dose was
54-7 mc. The temperature rose slightly for three days ; on the fourth day
the animal refused food and lost 1^ lb. in weight. There was a relative
decrease of the lymphocytes and increase of the polynuclears. There was
an increase of total nitrogen and phosphates in the urine ; the creatinin
remained constant.

The fourth injection was made on the fifty-second day ; the dose was
146-4 mc. The temperature was high before injection but soon fell. A few
hours after the injection there was vomiting and the passage of semi-solid
faeces. Food was refused. The animal lost 2 lb. in weight in five days
and was seriously ill. The white cells fell to 1,400 with a great reduction
in the lymphocytes to 3 per cent. ; the polj^iuclears increased to 95 per cent.

Histologically there were fatty and granular degeneration of the liver,
congestion of the kidneys, and slight degeneration of the tubule cells. The
splenic cells were pigmented and the follicles small and scanty, the organ
was congested and fibrosed. In the bone marrow of the head of the femur,
fat replaced the lymphoid cells. The pancreas, thyroid and parathyroids,
stomach, and small intestine showed no change.

The experiments show that the same effects on the blood may be
obtained by the intravenous injection of the active deposit of radium
emanation as by X-rays, and that definite physiological reactions follow
the injections.

Conclusions. Large intravenous doses produced a large drop in the
leucocytes up to 80 per cent., and a reduction of the red cells to about
25 per cent. Repeated injections apparently produced a marked decrease
of lymphocytes. Injections produced severe digestive disturbances and
a marked drop in body-weight. In many cases there was a rise in tempera-
ture, probably in response to a toxic condition. The larger doses were
followed by great increase in the total nitrogen, urea, &c., in the urine.
Relatively small doses, after the organism had been injured, produced
definite changes.

Histologically there was great congestion of the principal viscera.

When treating patients the dose must vary according to the physical
condition and a second dose should be smaller than the first.

P. L.-B.

CiiUZET, RoCHAix, et EoFMAN. Action bactericiilo du radium sur le bacille
pyocyanique. [The bactericidal action of radium on B. pyocyaneus.]

Reunion hiologique de Lyon., 1920, July. {J. de radiol. et d'eledrol, 1920, 4,
525.)

This is a very important piece of work from the point of view of
radio-biology. The authors, using a tube with walls of 0-5 mm. of platinum,
have employed a higher proportion of gamma-rays than that ordinarily used
in physiological experiments. These tubes, indeed, allow less than half the
beta-rays and almost all the gamma-rays to pass through.

The tube used by them contained 50 mg. of RaBr2.2H20, that is,
about 25 mg. of radium element.

188 ABSTRACTS

They did not determine the intensity of the field around the tube and
in the various layers of the cultures, and as the culture tubes measured
1 cm. in internal diameter, they were forced to have fields of action differing
greatly according to distance, therefore the following results can only be
regarded as mean figures. This does not lessen their value.

The first experiment was on a 24-hours' culture of B. 'pyocyaneus in
peptone broth. The irradiation lasted three days at a temperature of 16°C.
The action of radium under these conditions was nil.

A second experiment made at room temperature with tubes immediately
after inoculation, and seven days' irradiation, clearly showed a delay of
twelve days in growth of the culture.

The third experiment was made on cultures kept in ice. These cultures
were also kept in a living but arrested condition. Nine days' irradiation
under these conditions sterilized the culture. That is, a drop of the irradiated
culture when re-inoculated remained sterile, whereas a drop of a control
culture kept at the same temperature during the nine days began to grow.

A control experiment has elsewhere shown that the retarding or steri-
lizing action is direct and is not produced indirectly through a chemical
reaction on the medium.

From these experiments the authors conclude : (1) that radium appears
to be without action when acting for 24 hours after inoculation ; (2) that
the action of radium on young cultures just beginning to grow is only
retarding ; (3) that if the growth of the culture is retarded by cold, the
action of radium is clearly bactericidal. These results are comparable with
those obtaining in seeds under the action of radium. P. L.-B.

MEDICAL SCIENCE

ABSTRACTS & REVIEWS

Volume IV. Number 3 June 1921

CONTENTS

REVIEWS : page

TYPHUS 191

WHOOPING-COUGH 201

VACCINATION 205

GONORRHOEA 210

CHANCROID 218

SURGICAL TREATMENT OF CHRONIC INTESTINAL STASIS . . 221

MELANIN, MELANOMA, MELANOTIC CANCER 229

ACUTE SUPPURATION ABOUT THE WRIST TREATED BY INCISION

DIVIDING THE ANNULAR LIGAMENT 236

ABSTRACTS :

SURGERY * .... 230

NEUROLOGY 242

PATHOLOGY AND BACTERIOLOGY 255

BIOCHEMISTRY 273

RADIOLOGY 283

MEDICAL RESEARCH COUNCIL

The viscount GOSCHEN, C.B.E. (Chairman)

WILLIAM GEAHAM, M.P.

The Hon. EDWAED F. L. WOOD, M.P. {Treasurer)

C. J. BOND, C.M.G., F.E.C.S.

Professor WILLIAM BULLOCH, M.D., LL.D., F.E.S.

T. E. ELLIOTT, C.B.E., D.S.O., M.D., F.E.S.

HENEY HEAD, M.D., F.E.S.

Professor F. G. HOPKINS, D.Sc, F.E.C.P., F.E.S.

Major-General SIE WILLIAM LEISHMAN, K.C.M.G., C.B., F.E.S.

Professor NOEL PATON, M.D., F.E.S.

SIE WALTEE M. FLETCHEE, K.B.E.. M.D., Sc.D., F.E.S. {Secretary).

The Council are indebted to the following for editorial superintendence in
the subjects named :

Medicine . . . . J. D. EOLLESTON, M.D.

Surgery . . . . W. G. SPENCEE, M.S., F.E.C.S.

Pathology and Bacteriology W. BULLOCH, M.D., LL.D., F.E.S.

Neurology . . . F. M. E. WALSHE, M.D. F.E.C.P.

Radiology . . . W. S. LAZAEUS-BAELOW, M.D., F.E.C.P.

SIDNEY EUSS, D.Sc.

Biochemistry . . . C. G. L. WOLF, M.D.

All communications on editorial matters should be addressed to

E. SCHUSTEE, D.Sc,
Assistant Secretary, Medical Eesearch Council,

National Institute for Medical Eesearch,

Hampstead, N.W. 3.

REVIEWS

TYPHUS

Epidemiology. According to Hunter, the Serbian epidemic of 1915
was the most sudden in origin, greatest in extent, and most quickly arrested
of any epidemic of a like kind in history. It lasted for about six months
and maintained its maximum for about two months. Other epidemics have
lasted 1^3 years, and maintained their maximum for periods of 12 (Irish)
or 18 months (English epidemic). Like the Irish epidemic of 1846-1848,
the Serbian epidemic was one of relapsing fever and typhus combined. The
first in origin was relapsing fever, the number of cases in hospital at the
end of December 1914 being 2,184 as compared with only 200 of typhus.
By the end of January the numbers of relapsing fever and typhus cases were
5,122 and 1,100 respectively, by the end of February 7,000 and 4,000
respectively, and by the end of march 8,100 and 8,000 respectively. There-
after the proportions altered ; at the end of April there were 3,260 cases of
relapsing fever and 6,300 of typhus, and by the end of May 1,600 of relaps-
ing fever and 2,860 of typhus. The mortality was 30 per cent, in January
and February, and rose in a week or two to 40 per cent, in March. As
usual, it was highest among the doctors ; out of an original total of 450
Serbian doctors 100 died and 200 were rendered unfit for duty.

Cantacuzene draws attention to two remarkable features of the
Roumanian epidemic of 1917-18. In the first place, concurrently with the
outbreak of typhus, an abnormally virulent epidemic of relapsing fever
developed, and both epidemics reached their highest incidence and mortality
at the same time. The epidemic of relapsing fever rapidly declined in
April 1917, and ceased entirely at the beginning of May, whereas the
epidemic of typhus did not come to an end till June. The second remark-
able feature of the epidemic was the fact that scarlet fever, which is usually
extremely frequent and severe in Roumania, almost entirely disappeared
during the epidemic of typhus. The average mortality in the Roumanian
epidemic in the hospitals at the front and at the base was 15-17 per cent.,
ranging from 12-27 per cent, according to the various hospital centres. In
the medical staff" the mortality was 41 per cent., death being due in the
great majority of cases to the bulbo-pontine form of the disease {vicle also
Medical Science 1920, 1, 561).

According to Goodall, for the period January 1, 1916, to December 31,
1919, there were at least 431,200 cases of typhus in Congress Poland and
Galicia combined. The number was probably higher, for there was little
doubt that not a few cases escaped being recorded. During January and
February 1920, 12,098 cases were notified in Congress Poland and 34,476 in
Galicia. The epidemic was widely spread and prevailed at one time or
IV. P 2

192 REVIEWS

another, with varying attack rate, all over Poland in 1918. Early in 1919
the whole country was more or less invaded, but the districts which suffered
most were those in the east and south-west. Galicia and Volhynia were
also severely aflfected.

Ruysch states that prior to 1918 typhus made only a sporadic appearance
in Holland, only 9 cases having occurred between 1911 and 1917. This was
all the more remarkable as in several neighbouring countries the disease
was more or less prevalent, and thousands of" persons had been crossing the
frontier from infected areas ever since the first year of the war. In 1918
the first cases of typhus in Holland, which occurred at Amsterdam, were not
recognized as such and were diagnosed as typhoid fever. A few days after
admission to hospital the true nature of the disease was discovered both
by clinical examination and the Weil- Felix reaction. It is probable that the
late diagnosis favoured the extension of the epidemic. 17 cases occurred
at Amsterdam and 40 at Urk, a little island in the Zuider Zee (vide Medical
Supplement, 1919, 2, 264). The character of the epidemic in 1918 was
mild, but in January 1919 it assumed a more severe form, 20 districts being-
attacked. 120 cases occurred in January, 400 in February (a large number
of these being in Rotterdam, Haarlem, and Delft), 300 in March, and 13
in April. The last case occurred on May 1. From January 1— May 1, 1919,
there were 541 cases at Rotterdam, of which 87 were fatal. The mortality
increased with the age of the patient, being nearly 50 per cent, between 60
and 74.

The epidemic of typhus in Rotterdam during the early part of 1919 is
described by Kramer (1). The disease broke out with great suddenness and
rapidly spread all over the town. In the week January 26-February 1, 6
cases were notified, and in the following weeks 126, 145, 170, and 119. As
the result of the measures taken, viz. rapid removal to hospital, observation
of contacts, delousing, and disinfection, the epidemic speedily declined in
March. In the first week of April there were only three cases, and in the
second week only one, the last. Of 194 cases admitted into two large
school buildings which had rapidly been converted into hospitals, 141 were
found to be suffering from typhus, and the remaining 53 from a variety of
diseases, 21 of which were cases of typhoid, an epidemic of which was pre-
valent at the same time. Of 130 cases admitted during the febrile period

29 died, a mortality of 22 per cent. In 20 of these death took place during
the acute stage, 2 died of pre-existing diseases (chronic bronchitis and
tuberculosis) and 7 of complications (pneumonia, nephritis and haematemesis).
The comparative mildness of the disease in early life and its severity in
later years are shown by the fact that of 77 cases under 30, only 4 died,
a mortality of 5 per cent., while between 30 and 40 the mortality was 18
per cent. ; between 40 and 50, 43 per cent. ; between 50 and 60, 70 per cent. ;
and between 60 and 70, 60 per cent. The mortality in the two sexes above

30 showed a distinct diff"erence, about one-third of the cases in women being-
fatal as compared with one-half of the cases in men.

According to Pulido, three important outbreaks of typhus have recently
occurred in Spain. The first, consisting of about 50 cases, occurred in the
province of Burgos in June 1918, the second in the province of Murcia in
January to May 1919, and the third outbreak, in which there were over
1,500 cases, in the provinces of Almeria and Granada in July 1919. This
last epidemic was remarkably mild, for with the exception of two districts
in which it was 50 per cent., the mortality did not amount to 4 per cent.

TYPHUS 193

Jorge states that thouuh typhus is endemic in Portuoal, no important
outbreaks had occurred until the endemic of 1918-19 in Oporto and the
north of Portugal, only sporadic cases or localized epidemics having occurred
since the Peninsular Wai-, when typhus caused more deaths than Napoleon's
army among the British expeditionary force. From the onset of tlie
endemic at Oporto, in December 1917, to the end of December 1918, 6,254
cases of typhus were notified at Oporto with 1,203 deaths, a mortality of
19-2 per cent., and from January to the end of August 1919 there were
2,781 cases with 278 deaths, a mortahty of 9-7 per cent.

Schweinburg records an epidemic of over 800 cases of typhus which
occurred among German prisoners in Orenburg (Russia) in December 1915.
The epidemic was a mild one and complications were rare. No case of
gangrene occurred. The mortality was about 7 per cent. Schweinburg
kept himself, his wife, and two soldiers who were in constant contact with the
patients free from lice by soaking their under-hnentwdce daily in petroleum.

Zlocisti, who was in charge of the German Red Cross Hospital at
Constantinople, states that of 1,716 typhus patients admitted between May
1916 and June 1918, 310 died— a mortality of 18-07 percent., which closely
corresponds to the figure given by Murchison of 18-78 per cent. No deaths
occurred in the August of 1916 or 1917, the decline of the disease in the
summer being due to increase in individual hygiene and the injurious effect
on the lice of light, heat, and the damp skin of the sweating man. Age was
the most important factor in the prognosis. Among children the mortality
was almost nil, while in old age it was nearly 100 per cent., and between
those two extremes there was a regularly rising curve. Race was of
importance as regards the mortality only in so far as alcohol was con-
cerned. The lower mortality among the Jews was due to their temperate
habits.

Clemow states that typhus was rarely seen in Turkey before the war,
and in Constantinople it was scarcely knowm as an indigenous disorder.
Since the outbreak of the war, however, it has become widely epidemic
throughout the greater part of the country. As regards its recent prevalence,
the disease became epidemic in February, March, and April 1920 in Con-
stantinople mainly as the result of the influx of Russian refugees after the
defeat of Denikin's army. The highest number of cases in any one week
(that ending March 13) was 78. In the summer the epidemic greatly
declined, but the disease never wholly disappeared, and in the winter it
became active again with the arrival of a still larger crowd of refugees from
the Crimea after the collapse of Wrangel's army. Clemow estimates that the
total number of known cases of typhus during 1920 was between 600
and 700.

An outbreak of eight cases of mild typhus in a home for foreign work-
men at Paris is reported by Legry, Courcoux, and Lermoyez. Two cases
from the same source, one of which recovered and the other died, are also
reported by Labbe and Hutinel. The disease was at first mistaken for in-
fluenza, and it was not until the Weil-Felix reaction was performed at the
Pasteur Institute that the correct diagnosis was established.

At a meeting of the Societe medicale des hopitaux de Paris on June 11,
Netter and Salanier reported an isolated case of typhus in a lady, aged 28,
wdiich had been contracted at Cracow in Poland, showing that the disease
does not spread in families where cleanliness is observed. The disease is
transmitted by lice only, and owing to her having changed her under-linen

194 REVIEWS

several times in the course of her journey from Cracow to Paris, the patient
had not brought any lice with her. In the subsequent discussion Renault
stated that he had seen three simultaneous cases of tj^phus, in a camp of
Polish workmen near Arras, who had contracted the disease before leaving
Poland.

A proof of the important and perhaps exclusive role played by lice in
the transmission of the disease is also given by Kramer (2) in his account of
the epidemic at Amsterdam. The sanitary employees who were engaged in
the transport of the patients and the disinfection of houses were required
to keep their hair and beard closely shaved, to wear special clothes when on
duty, and at the end of their day's work to return home in their own clothes.
After this regulation had been made, eight employees contracted tj^phus,
but although they remained at home some days before removal to hospital,
no case broke out in their families.

Symptomatology. Lowy contests the truth of Jiirgens's dictum that
one case of typhus is just the same as another (vide Medical Sup'plement,
1918, 1, 90), since typhus without eruption, attacks with a rudimentary rash,
and those wath a severe haemorrhagic eruption represent clinically distinct
types of the disease. He records three cases of atypical typhus in children
aged 5, 8, and 10 years respectively, in whom the fever lasted only five to
seven days and was accompanied by very little general disturbance. In
spite of the most careful examination no rash could be detected, but the
diagnosis of typhus was established by the Weil-Felix reaction, which was
positive in 1 : 200-1 : 1,600, as well as by the existence of an epidemic.

At a meeting of the Bucharest Medical Society, Constantinesco and
Sloboziano reported two cases of typhus without eruption in which the
clinical diagnosis was confirmed by the Weil-Felix reaction, which was
positive in a dilution of 1 : 1,600. In the subsequent discussion Daniel opolu
stated that he had never met with an example of typhus w^ithout eruption
among a thousand cases of the disease, and V^ignal declared that one should
be very careful in making such a diagnosis. It was better to say ' without
perceptible eruption '. In some cases the rash was very famt and transient.
Sometimes, as in typhoid fever, it could only be seen in the scapulo- vertebral
region. Moreover, in subjects with a pigmented skin like the Tziganes in
Roumania, it might not be visible to the naked e^^e, but could be detected
by examining the skin through blue glasses, when the eruption appeared in
the form of black spots.

According to Kramer (2) widely divergent figures are given by different
writers as to the duration of the incubation period in typhus. It is
generally supposed to be from 9-12 days. The period may, however, be
shorter, as was shown by the case of a nursing sister who went to Urk in
September 1918 to nurse typhus, and on the eighth day after her arrival
was severely ill with the disease. At the beginning of the epidemic at
Rotterdam in 1918-19, contacts were isolated for 14 days, but subsequently
this period was prolonged to 18 days, because in the second half of February
two or three days after release from quarantine, tw^o cases broke out in one
family. The garrison at Rotterdam was isolated for 21 days, but as a rule
isolation of contacts for 18 days, reckoning from the doy of delousing is
sufficient.

Gane describes a case of relapse in a man aged 21, who had a mild
attack of typhus followed by a similar attack five days after the temperature
had become normal. The eruption was typical of typhus in both attacks.

TYPHUS 195

The diagnosis of enteric and relapsing fever was excluded in both attacks
by examination of the blood.

Cantacuzene also reports a case of relapse in which there was an
interval of 3^ months between each attack. In both cases the attack was
of moderate intensity and uncomplicated, the second attack being an exact
repetition of the first.

Dumitreseo-Mante. of Bucharest, describes the followinii; three forms of
pulmonary cougestiou in typhus: (1) simple congestion, (2) perituberculous
congestion, (3) pseudo-tuberculous or pseudo-phymic congestion. In the
last form the congestion is localized at the apex, and presents the clinical
and radibscopic appearances of pulmonary tuberculosis, but repeated
examination of the sputum shows an absence of tubercle bacilli. The
general condition is usually good, and complete recovery takes place in
a few days or weeks. Although similar phenomena have been described in
influenza and malaria, Dumitresco-Mante states that pseudo-tuberculous
congestion which lie observed in 10 out of 254 cases, has not previously
been described in typhus. One of the factors of this congestion is the
intense vasodilatation which occurs in typhus. The localization at the apex
is difficult to explain and may possibly be due to a latent tuberculous focus.
It must, however, be definitely distinguished from the congestion which
occurs round a focus of active tuberculosis, and in most cases has a grave
and progressive evolution.

Stroe examined the cerebrospinal fluid in 15 cases of severe typhus, all
of which ended fatally, and found the streptococcus present in each case.
In 12 of these it was also present in the blood. Stroe considers that the
presence of this organism in the cerebrospinal fluid was due to septicaemia.
Its absence in 3 cases does not negative this hypothesis, as a single blood-
culture does not possess an absolute value. All the fluids were examined
cytologically and showed the changes described by Danidlopolu (vide
Medical Sivppleinent, 1918, 1, 91), Devaux {ibid., 385), and others, the
presence of the streptococcus in no way aftecting the cell count.

Cantacuzene states that the general physiognomy of the Roumanian
epidemic of 1917-18 was entirely difterent from that of the Serbian
epidemic of 1915, which was characterized by the enormous proportion of
cases of dry gangrene. In the Roumanian epidemic, cases of gangrene were
extremely rare and did not amount to more than one case in a thousand.
In the few cases which did occur the lower extremities only were afiected,
and the extensive areas of gangrene, involving the whole of the abdominal
wall, such as were seen in the Serbian epidemic, were not observed. On the
other hand the Roumanian epidemic was characterized by a bulbo-pontine
syndrome of which hiccough, dysphagia, dyspnoea, and trismus were the
principal features, some cases closely resembling rabies and tetanus.

Pfeiffer records a case of typical right hemiplegia and aphasia in
a woman aged 26, which occurred on the first day after the temperature
had become normal. Some improvement took place in the course of the
next few months, but slight contracture of the elbow and wrist developed.
Pfeiffer attributes the complication to a large embolic or thrombotic focus in
the region of the left middle cerebral artery.

Moszeik reports a case of lethargic encephalitis following typhus, in
a girl aged 18, to show that this syndrome may follow other infectious
disease than influenza.

Grossfeld deals wdth the onychodystrophy of the fingers and toes

196 REVIEWS

following typhus which was described by Vogel in 1870 and by Murchison
in 1873, and consisting in a groove 2-3 mm. broad running across the nail.
It appears in the second month of convalescence and reaches the free border
of the nail at about the sixth month. In several cases the retrospective
diagnosis of typhus was made in convalescents who had had no history of
illness.

The aural and laryngeal complications of typhus are discussed by
Costiuiu, of the Otorhinolaryngological CHnic of Bucharest, who states that
during the Roumanian epidemic of 1917-18 nearly 70 per cent, of the
patients had aural complications. In the early stage of the disease the
middle ear only was affected, but in 10 per cent, the internal ear was also
involved later. Recovery from otitis media was almost the rule, but
recurrences were not infrequent. In otitis interna the results were less
favourable. Improvement was obtained but was less lasting. Laryngeal
complications, which were observed in about 15 per cent, of the cases, usuall}^
developed in convalescence. Diphtheria without concomitant faucial
involvement was frequent. The evolution of these cases was unfavourable
because the patient was unable to dispense with the tracheotomy tube.
Costiniu therefore recommends that tracheotomy should only be performed
in severe cases and never at the onset. Naso-bucco-pharyngeal antisepsis,
when carried out from the first, definitely reduced the incidence of both aural
and laryngeal complications and rendered them less severe when they did
occur.

According to Vaudremer, hypopyon is a relatively frequent complication,
as he found it in 12-8 per cent, of the cases of typhus in Epirus. As a rule
it appears at the height of the disease and only in severe attacks, but some-
times it is delayed until convalescence. Its appearance is announced by
violent pain in the eyeball and frontal and periorbital regions corresponding
to the eye affected. When it develops in patients who are not moribund,
it should be treated without delay, as recovery takes place without loss of
the eye if an operation is performed at once.

Strominger, of Bucharest, when in charge of a urological section in
a Roumanian military hospital, observed a large number of patients suffering
from cystitis which had developed from six weeks to two or three months
after an attack of typhus or relapsing fever. In some cases slight symptoms
had been present during the fever and after a period of remission had become
aggravated. Examination of the urine showed that the cystitis was not
caused by exogenous infection except in one case where the presence of
streptococci was due to frequent catheterization. In addition to the absence
of micro-organisms and inflammatory symptoms, the late appearance of a
complication like gangrene of the extremities and genitals is in favour of an
exclusively toxic origin. The prognosis as a rule is good, but may be serious
and even fatal when there are extensive renal and vascular lesions.

Blood. According to Cazeneuve, who examined the blood in 13 cases,
typhus causes considerable changes in the leucocytes, viz. a variable but
constant hyperleucocytosis, a pronounced neutrophil polynucleosis, eosino-
philia, and a definite myelocythaemia.

Cantacuzene states that association with other diseases, especially
cholera and relapsing fever, was characteristic of the Roumanian epidemic.
All the cases of typhus in which cholera supervened were rapidly fatal, but
relapsing fever did not appear to have any effect on the course of typhus or
to aggravate the prognosis. Cantacuzene also refers to the action of typhus

TYPHUS 197

or latent tuberculosis. Without having the fulminating effect of relapsing
fever, it is certain that in a very large number of cases of t j-phus, in which
before the attack no appreciable evidence of lung disease was present,
tuberculosis subsequently developed with great rapidity.

Glatard (1) records an epidemic of .'206 cases of typhus at Oran in
Algeria with 47 deaths— a mortality of 2.2 percent. The incubation period
varied from four to twelve days. Conjunctival infection was an early and
very constant sign, being present in cases in which the eruption did not
appear till late or was absent altogether. As regards the character of the
eruption, petechiae were frequently absent, the typical lesion being a macule,
which was at first pink and then became darker, and did not fade on
pressure. The duration of the disease ranged from 16 to 18 days. In fatal
cases death occurred either at the height of the disease from myocardial,
pulmonary, or meningeal complications, or during its decline from collap.se
or nervous complications such as bulbar palsy or encephalitis.

Diagnosis. Lapin and Senevet, of the Pasteur Institute of Algiers,
examined the Weil-Felix reaction in 158 cases of clinical typhus, and 20
controls with the following results : (1) None of the controls gave a po.sitive
reaction even in a dilution of 1 : 50; (2) of the 158 clinical cases 145 gave
a positive reaction at least once, and of the 13 negative cases 5 had the
reaction performed only once, 4 died before the end of the febrile period,
and 4 were persistently negative. The agglutinating power of the cerebro-
spinal fluid was found to be very feeble. In 4 patients in whom the serum
agglutinated Proteus X 19 at 1 : 500, the cerebrospinal fluid caused no
agglutination at 1 : 50. In one patient in whom the serum agglutinated at
1 : 2,000, the cerebrospinal fluid agglutinated feebly at 1 : 50, and in another
patient in whom the serum agglutinated at 1 : 3,000, the cerebrospinal fluid
agglutinated at 1 : 100. The writers conclude that the Weil-Felix reaction
is of great value in the diagnosis of typhus when it is positive, but as it
only becomes positive towards the end of the disease no account should be
taken of a negative reaction when the clinical symptoms justify the diagnosis.

Van der Reis records a case admitted to hospital as influenza in which
the diagnosis of typhus was established by the skin reaction described by
Friedberger and himself seven days before the Weil-Felix reaction became
po.sitive (vide Medical Science 1920, 1, 563-4).

Prophylaxis. In a paper discussing the principles of prophylaxis of
typhus in armies on active service, and their application to the civilian
popuUition in peace time, Armand-Delille describes Sarrailhe's method, which
was systematically employed in the French army of tha east during the
Macedonian campaign. The clothes were ironed on their inner surface and
especially along the Hning. Although a single ironing did not destroy the
lice and their ova, when the ironing was performed every seven days it was
equivalent to a process of tyndallization, and it was absolutely efiicacious if
repeated for several weeks in succession. A generation of lice requires
several days after hatching to furnish insects capable of reproduction. If
therefore most of the lice and their ova are destroyed every seven days, in
four or five weeks the evolution of the generations will be completely
destroyed, as Sarrailhe and Rdcamier showed in a colonial regiment on the
Albanian front.

Nicolle and Conseil have found that the serum of typhus convalescents
and of monkeys who have recovered from the experimental disease possesses
definite preventive properties. The immunity conferred, however, is only of

198 REVIEWS

short duration and the convalescent's serum is only active when it has been
obtained during the first few days after the temperature has become normal.
During a recent outbreak of typhus at Tunis, the writers employed the
method in 7 cases, and none of the persons so treated contracted the disease.
4 were given a single injection of 20 c.c. and 8 two injections with a few
days' intervp,! between each.

According to Hunter the suddenness of the onset of the Serbian
epidemic, dating from a particular day, was directly related to measures
for stopping movements of people, and its recurrence, also dating from
a particular day, was directl}^ related to the resumption of such movements.
The measures for checking the epidemic were the temporary cessation of
railway traffic, suspension of leave from the army, and the improvisation of
a method of disinfection which could be at the disposal of every one, especially
the provision of ' barrel disinf ectors '.

Treatment. According to Vaudremer, the treatment of typhus, which
should be commenced as soon as possible, should be conducted on the follow-
ing lines: (1) intramuscular injections of camphor oil (1 in 10) in doses of
2 c.c. every two hours if necessary ; (2) injections of equal parts of camphor
oil and ether in cases of profound asthenia and cardiac insufficiency ; (3)
digitalis by mouth or subcutaneous injections of digitalin systematically
from the onset ; (4) adrenalin by mouth or subcutaneously in doses of 1-2 mg.
daily during the febrile stage, and later in cases of hypotension ; (5) hydro-
therapy should be forbidden, bad results being obtained owing to the profound
asthenia and myocardial weakness.

Zielinski, of Warsaw, has treated 232 cases of typhus by hypodermic or
intravenous injections of the patient's cerebrospinal fluid (vide Medical
Supplement 1918, 1, 176). He considers that this treatment should be
employed in every severe case, especially when dangerous symptoms arise
involving the nervous and circulatory system. The amount of fluid with-
drawn should not exceed 20 c.c. and of that injected 10 c.c. If a re-injection
is required, 3-5 c.c. may be given two or three days after the first injection.
The cerebrospinal fluid obtained by lumbar puncture loses its activity at the
end of a fortnight. The most favourable time to give the injection is from
the 7th-10th day of disease, but in cases in which severe symptoms appear
sooner, the injection can be given before the 7th day. Zielinski states that
the method has yielded excellent results, the mortality among typhus cases
so treated having fallen from 9 to 5 per cent.

Glatard (2) has treated 114 cases of typhus by intravenous injections of
urotropin. The jdoses given at first were 1'50 gm. for adults and 0-75 gm.
for children, but were afterwards raised to 3 gm. daily. The number of
injections given varied from one to eight, the average being three. The
results were as follows : (1) in the great majority of cases urotropin given
intravenousl}^ favours defervescence, which occurs as a rule after the second
injection ; (2) it causes abundant diuresis, and therefore facilitates elimination
of toxins ; (3) it lowers the mortality, which was 14 per cent, among cases
treated by urotropin as compared with 29 per cent, among cases not
so treated ; (4) it should not be used after the temperature has fallen, the
myocardial asthenia being more suitably treated by camphor oil, strychnin,
and nucleinate of soda injections.

Kersten states that intravenous injections of collargol or ' fulmargin ',
a finely colloidal silver preparation obtained by electrolysis, has a favourable
influence on the course of the disease. 5 c.c. of a 5 per cent, solution of

TYPHUS 199

collargol can be given daily for eight days, or an ampoule ol' ' fulniargin '
daily for seven days.

Monziols and Collignon treated 13 cases of typhus with an iodized
Proteus X 19 vaccine containing 1, ()()() ,()00,()()() organisms per c.c. in doses
ranging from 1-3 c.c. with the following results. The typhoid state
diminished, the tongue became moist, the delirium subsided, the temperature
and pulse ran a parallel course after the second injection, and the duration
of the disease appeared to be shortened. The average number of injections
given to each patient was seven. One death occurred among 13 treated
with vaccine as compared with two among 13 not so treated.

ABMAND-DEI.ILI.E, P. F. Prlncipes de la prophylaxie de typhus dans les
annees en campagne, leur application aux populations civiles en temps de paix.
Bull. Acad, de med., 1920, 3*^ ser., 83, 265-7.

Cantacuzene, J. L epidemie du typhus exantheniatique en Roumanie pen-
dant la derniere guerre. Bull. Soc. path, exot., 1920, 13, 269-90.

Cazeneuve, H. J. Les reactions cellulaires sanguines au cours du typhus
exantheniatique. Bull. Soc. path, exot., 1920, 13, 742-7.

CiiEMOW, P. G. Typhus in Turkey and adjoining countries : its recent preva-
lence. Lancet, 1921, i, 193-4.

CoNSTANTiNESco, C. D., et S1.OBOZIANO. Typhus sans eruption. Bull, et
mem. Soc. med. d. hop. de Bucarest, 1919, i, 39-45.

CosTiNiu, A. Les affections des oreilles et du larynx survenues comme com-
plications du typhus exantheniatique et de la fievre recurrente. Presse med.,
1920, 28, 453-4.

Dumitbesco-Mante. Congestions pseudo-phymiques dans le typhus exanthe-
niatique. Baris med., 1920, i, 505-6.

Gane, T. Typhus exanthematique a rechute. Bull, et mem. Soc. med. d. hop.
de Bucarest, 1919, i, 73-4.

Glatabd (1). Reflexions sur 206 cas de typhus exanthematique. Bull, et mem.

Soc. med. d. hop. de Par., 1920, 3^ ser., 44, 944-8.

Glatabd (2). Typhus et injections intraveineuses d'urotropine. Bull, et mem.

Soc. med. d. hop. de Par., 1920, 3^ ser., 44, 948-50.

GoODALL, E. W. Typhus fever in Poland, 1916-19. Proc. Boij. Soc. Med.,

1920, 13, Sect, of Epid. and State Med., 261-76.

Grosspeld, H. Ueber Onychodystrophie nach Fleckfieber. Wicn. Jclin.
Wchimhr., 1919, 32, 1109-10.

HuNTEB, W. The Serbian epidemics of typhus and relapsing fever in 1915 ;
their origin, course, and preventive measures employed for their arrest. Proc.
Roy. Soc. Med., 1919, 13, Sect, of Epid. and State Med., 32-158.

Jorge, R. Le typhus exanthematique a Porto en 1918-19. Bull, de Voffice
internat. d'hyg. pub., 1920, 12, 133-44.

Kebsten, H. E. Fleckfieber und kolloidale Silbermittel. Deutsche med.
Wchnschr., 1920, 46, 831-2.

Kbameb, p. H. (1). Mededeelingen over Vlektyphus, 11. Bijdrage tot de
klinik. Nederl Tijdschr. v. Geneeslc, 1920, i, 455-72.

200 REVIEWS

Kramer, P. H. (2). Mededeelingen over Vlektyphus, III. (Slot). Aanteeke-
ningen over het verloof van de Kotterdamsche epidemie. Nederl. Tijdschr. v.
Geneesk., 1920, i, 888-93.

Labbe, M., et HuTiiTEii, J. Deux cas de typhus exanthematique a Paris.
Bull, et mem. Soc. mccl. d. hop. de Paris, 1920, 3^ ser., 44, 565-9.

Lafiit, J., et Senevet, G. La reaction de Weil-Felix dans le typhus exanthe-
matique. Faible pouvoir agglutinant du liquide cephalo-rachidien. Bull. Soc.
path, exot, 1919, 12, 592-5.

Legry, Courcoux, et IiERMOYEZ, J. Note clinique surquelques cas benins de
typhus exanthematique observes a Paris. Bull, et mem. Soc. med. d. hop. deFar.,
1920, 3e ser., 44, 524-31.

LbwY, R. tJber atypische Fleckfiebererkrankungen. Wien. med. Wchnschr.,

1919, 69, 2142-5.

MoNZioiiS et CoiiiiXGNON. Essais de vaccinotherapie du typhus exanthema-
tique par un vaccin iode a Proteus X 19. Bull, et mem. Soc. med. d. hop. deFar.,

1920, 3e ser., 44, 462-3.

MoszEiK. Encephalitis epidemica nach Fleckfieber. 3Ied. Klin., 1920, 16,

879-80.

Netter, a., et Salanier, M. Un cas de typhus exanthematique contracts
en Pologne. Absence de contagion dans I'entourage de la malade. Bull, et mem.
Soc. med. d. hop. de Far., 1920, 3^ ser., 44, 804-8.

NicoiiiiE, C, et CoNSEii., E. Prevention du typhus exanthematique au moyen
du serum de convalescents chez les personnes contaminees par les poux des
malades. Compt. rend. Soc. de biol, 1920, 83, 991-2.

Ffeiffer, R. Typische Halbseitenlahmung im Verlauf eines Typhus exan-
thematicus. Wien. klin. Wchnschr., 1919, 32, 1073-4.

FuiiiDO, A. Lutte contre le typhus exanthematique en Espagne. Bull, de
VOffice internat. dliyg. pub., 1920, 12, 356-9.

BuYSCK, W. P. Lutte contre le typhus dans les Pays-Bas. Bidl. de VOffice
internat. dliyg. puh., 1920, 12, 360-3.

ScHWEiNBURG, E. Ueber Flecktyphus. Wien. Uin. Wchnschr., 1920, 33,
129-30.

Stroe, a. Streptocoque dans le liquide cephalo-rachidien des exanthematiques.
Bull, et mem. Soc. med. d. hop. de Bucarest, 1920, 2, 144.

Strominger, Im. Sur quelques troubles urinaires post-exanthematiques et
recurrentiels. Fresse med., 1920, 28, 876-7.

VAMT DER Reis. Fruhdiagnose eines Fleckfieberfalles durch die Hautreaktion
von Friedberger-van der Keis. 3Ied. Klin., 1920, 16, 601-2.

Vaudremer. Rapport clinique sur I'epidemie de typhus exanthematique
d':6pire. Ann. dliyg., 1920, 5e ser., 34, 197-215.

ZiELiNSKi, C. Traitement du typhus exanthematique par les injections du
liquide cephalo-rachidien. Fresse med., Suppl., 1920, 28, 1182-3.

Z1.0CISTZ, T. Zur Epidemiologie des Fleckfiebers (nach Erfahrungen aus der
Turkeij. Ztschr. f. Hyg. u. InfeUionsliranhh., 1919, 89, 387-415.

J. D. R.

WHOOPING-COUGH 201

WHOOPING-COUGH

Aetiology. Apert and Camhess^des draw attention to the fact that
both in France and abroad whooping-cough shows a marked predomin-
ance among the female sex. Thus, during the year 1919 150 girls were
admitted to the whooping-cough pavilion at tlie Hopital des Enfants
Malades, as compared with 88 boys. The statistics for the city of Paris
from 1894 to 1903 also show a higher whooping-cough incidence and mor-
tality among girls than among l)oys, thougli not so pronounced as tliat found
by the writers at. their liospital. The predilection of whooping-cough for
the female sex is all the more remarkable as all the other infectious diseases
of childhood, especially measles, scarlet fever, mumps, and diphtheria, are
more frequent and severe in the male sex.

Epidemiology. Reiche (1), of the Hamburg- Barmbeck Hospital, states
that, according to official statistics, of the four children's diseases, measles,
scarlet fever, diphtheria, and whooping-cough, the last has the lowest mor-
bidity but the highest mortality. In the period 1872-1912 the medical
statistics of the Hamburg State show that there were 60,253 cases with 7,355
deaths, or a mortality of 12-2 percent. This figure, Reiche admits, has only
a relative value, as by no means all cases of whooping-cough, especially
those of a mild character, were notified. It illustrates, however, the heavy
mortality associated with the disease, the mortality being particularly high
in hospitals where it is mainly the serious cases that are admitted. As in
the other diseases of children, the mortality from whooping-cough is highest
in early life and diminishes as age advances. Thus Hagenbach estimates
that the mortality is 26-8 per cent, in the first year of life, 13-8 per cent, in
the second year, and 3 per cent, in the third year. Of 66 deaths from pertussis
under six years of age, which occurred in Reiche's whooping-cough depart-
ment between April 1, 1914, and August 1, 1920, 16 cases were due to
tuberculosis which had been lighted up by whooping-cough, and a quarter
of these were caused by the miliary form. Another quarter of the deaths
was due to a severe secondary infection, such as influenza, diphtheria, and
lobar pneumonia, while two cases of infective meningitis were caused by
haemolytic streptococci rather than by the causal agent of pertussis. It was
thus clear that over a third of the deaths in Reiche's cases were not due to
whooping-cough, while in another 14 per cent, of the cases severe rickets or
the lymphatic diathesis was a favouring cause of death.

Symptomatology. Nasso records a case of whooping-cough in an infant
aged 14 months in whom the paroxysms were accompanied or sometimes
replaced by attacks of spasmodic sneezing. Death took place one morning
during an unusually violent attack, being probably due to spasm of the
glottis and cardiac syncope associated with spasmophilia. Nasso recommends
that all cases of whooping-cough in infancy should undergo antispasmodic
treatment even if there are no signs of spasmophilia present. In some
cases subcutaneous injections of magnesium sulphate should be given.

According to Reiche (2), little is known of the association of whooping-
cough and influenza. He reports an outbreak of influenza which occurred in
his whooping-cough ward during the epidemic of influenza in January 1920.
Of 16 cases in the ward 8 contracted influenza in the course of a few days,

202 REVIEWS

and shortly afterwards a child was admitted with both diseases, and died
three days later. The mortality among the nine cases was very heavy, as
six were fatal. In three of the cases there was a slight leucocytosis (14,800-
16^400) ; in the cases of early double infection there was the excessively high
leucocytosis of 172,000 per c.mm., while in four children the number of
leucocytes fell to 6,400, and even 3,000. The lymphocytosis characteristic
of whooping-cough was rapidly replaced by a predominance of the neutro-
phils on the supervention of influenza. With possibly one exception the
course of influenza in these cases was less a toxic than a pneumonic one. At
the autopsy there was a marked dilatation of the left ventricle resembling
that seen in diphtheria. In one case which proved fatal in three days
encephalitis was found jjost mention — a complication liable to occur in both
whooping-cough and influenza.

Reiclie (3), in the course of 62 months, has seen 29 cases of whooping-
cough complicated by convulsions. With 3 exceptions, aged 2, 3, and 4
years respectively, all the patients were infants in the flrst two years of life.
1 case showed tuberculous meningitis ; 3 bacterial infection of the meninges
due to streptococci, staphylococci, and pneumococci respectively; 1 thrombosis
of the meningeal veins ; and 6 other complications. The remaining 17 were
examples of pure whooping-cough convulsions. The spinal fluid in each case
was sterile, but showed an abundance of cells. There was a well-marked
lymphocytosis in the blood. Reiche considers that convulsions are due
to a serous whooping-cough meningitis.

Genoese examined the cerebrospinal fluid of six whooping-cough
patients, aged from 2^-6 years, with the following results : In every
case it was perfectly clear, under increased pressure, with a normal albu-
min and chloride content and without a fibrinous reticulum. There was an
absence of acetone, Boveri's reaction was negative^ and there was no increase
in the number of cells. There was considerable increase of reducing
substances, which was probably mainly due to meningeal congestion caused
by the violent and repeated attacks of coughing. Experimentally, this
hypothesis is confirmed by the fact that after spinal anaesthesia with stovain
or cocain there is an increase in the sugar in the cerebrospinal fluid without
hyperglycaemia. In such cases there is a marked congestion from local
irritation without inflammation, just as in whooping-cough, in which there is
a disturbance of the cerebral circulation and subsequent stasis.

Hess, of the Frankfort University Children's Clinic, came to the follow-
ing conckisions from examination of the blood in whooping-cough patients :
Lymphocytosis in whooping-cough is essentially caused by the paroxysms.
Each attack produces a distinct increase in the total number of leucocytes
with predominance of the lymphocytes. When there is a long interval
between the attacks, the increase sometimes ceases, but normal values are
not observed, both leucocytosis as a whole and relative lymphocytosis per-
sisting. Very high values are found in the paroxysmal stage, and the
highest of all during convulsions. Hess attributes the lymphocytosis to the
pressure exercised by the abdominal and respiratory muscles on the spleen
and thoracic duct, which are the ' central depots ' for lymphocytes.

Treatment. Intramuscular injection of ether in the treatment of
whooping-cough is advocated by Audrain of Caen ; Weill and Dufourt and
Gley vod of Lyons ; and Cheinisse of Paris. The injections are given in the
upper part of the buttock. The dose is 1 c.c. up to the age of 7 or 8 months,
and in older children 2 cc, repeated every two days. According to Weill

WHOOPING-COUGH ^03

and Dufourt, who ret^arcl injection of ether as far superior to any other
treatment of pertussis, the ether acts in two ways, (1) by reducing the
number of daily paroxysms, (2) by attenuating their violence and shortening
theii- duration. In a few days' time, as the result of a daily injection, the
childi-en liave only abortive attacks not accompanied by vomiting. It
is unnecessary to continue the treatment when there are not more than four
or five paroxysms a day.

Gleyvod"i who reports eight cases in children aged from 2^ months to
8 years treated by this method in Weill's clinic, states that the first injections
always have a more striking effect than the subsequent ones, the organism
apparently becoming habituated to the ether. He maintains that there is no
contra-indication to the use of ether when employed in doses of 1 or 2 c.c,
and that it acts as an energetic cardiac stimulant in febrile forms of
whooping-cough and those associated with much general disturbance and
severe pulmonary complications.

From its use in 115 cases the vast majority of which were in children
aged from a few weeks to 14 years, Macht has found that the administration
of l)euz3l benzoate solution, either alone or preferably with small doses
of benzaldehyde had a palliative, though not curative, effect on the violence
and number of the whooping-cough paroxysms. 5-40 drops of a 20 per
cent, solution of benzyl benzoate were given three or four times a day and
oftener, according to the age of the patient and severity of the disease.
The beneficial action of the drug is attributed by Macht to (1) its anti-
spasmodic effect on bronchial spasm, (2) its sedative effect on skeletal
muscle, (3) its anaesthetic effect on the larynx, (4) its expectorant properties,
(5) its antiseptic action.

McMurray also claims to have obtained immediate improvement in
cases of whooping-cough by the use of benzyl benzoate in doses of 5—30
minims every four hours without any undesirable results.

Lederer has treated 25 cases of pertussis by painting the throat every
two daj's with a 2 per cent, solution of silver nitrate as recommended by
Ochsenius. In the great majority of cases good results were obtained, the
paroxysmal stage being considerably shortened, the frequency of nocturnal
attacks diminished and long-standing attacks rapidly cured. Lederer
attributes the success of the treatment to suggestion and not to a specific
bactericidal action, and recommends that the method should be reserved for
older children of a neuropathic disposition in whom the attacks have lasted
a considerable time but without any complications. In such cases the
treatment maj' produce an immediate cure.

Kleinschmidt has recently employed diathermy in a large number
of cases of whooping-cough, and claims to have considerably shortened the
duration of the disease thereby. The patient's age was of no importance,
the youngest child being only nine months old, so that there could be
no question of suggestion accounting for the success of the treatment.

Although vaccines for the prevention or cure of whooping-cough have
lieen in use for the past eight years. Freeman has, until lately, been
of opinion that they did not modify the course of the disease, and he
had never seen a case prevented by their use. Recently, however, he has
observed good results from the use of fresh vaccines in cases where vaccines
three weeks old had no effect. The dosage used in his cases was half
a billion for the first dose, one billion for the second dose, and two billion
each for the third and fourth doses.

204 REVIEWS

Spolverini reports the results of the prophylactic use of whooping-cough
vaccine in 46 cases and of its curative use in 98 cases at the Paediatric Clinic
at Rome. He found that prophylactic inoculation with a Bordet-Gengou
vaccine, if carried out before the onset of the specific symptoms, gave excel-
lent results, failures occurring in only 7 per cent, of the cases. Vaccine
therapy was generally useless if employed 18-20 days after the onset, when
typical paroxysms had already developed, and the Bordet-Gengou bacillus
could no longer be found in the sputum. On the other hand, the treatment
was successful if adopted within the first ten days of the disease, when the
Bordet-Gengou bacillus could easily be found in the sputum. To ensure
success larger doses were required, viz. two to four or even six thousand
million per c.c, according to the age of the patient. The injections were
repeated on alternate days. For prophylaxis three were usually sufficient,
and for curative purposes six or seven were required.

Apert, E., et CAMBESSEDi:s. Influence du sexe sur la frequence de la coque-
luche. Bull, et mem. Soc. med. d. hop. de Far., 1920, 3^ ser., 44, 324-6.

AuDBAiN, J. Le traitement de la coqueluche par I'ether. Bull, et mem. Soc.
med. d. hop. de Par., 1920, 3^ ser., 44, 795-9.

Cheinisse, L. Les injections intramusculaires d'ether contra la coqueluche.
Presse med., 1920, 28, 526-7.

Freeman, R. G. The use of fresh vaccines in whooping-cough, lied. Rec.,
1920, 98, 762-3.

Genoese, G. Sul comportamento del liquido cefalo-rachidiano nella pertosse.
Policlin., 1920, Sez. Prat., 27, 291-6.

GiiEYVOD, P. Le traitement de la coqueluche a la periode des quintes par les
injections intramusculaires d'ether. Theses de Lyon, 1919-20. 80.
Hess, R. Zur Keuchhustenlymphocytose. Ztschr. f. Kinderheilk., 1920, Orig.
27, 117-26.

Kleinschmidt, K. Diathermiebehandlung der Pertussis. Med. Klin., 1920,
16, 1206.

Ledereb, R. Die Behandlung des Keuchhustens mit HoUensteinpinselungen.
Wien. Jclin. Wchnschr., 1920, 33, 1049-51.

Macht, D. I. An experimental and clinical therapeutic study of whooping-
cough. Johns Hopkins Hasp. Bull, 1920, 31, 236-8.

McMuRRAT, T. E. The benzyl benzoate treatment of whooping-cough.
N. YorkM. J., 1920, 112, 122.

Nasso, I. Morte improvvisa in un caso di pertosse. Pediatria, 1920, 28,
365-6.

Reiche, F.(1). Die Sterblichkeit an Keuchhusten. Med. Klin., 1921, 17,
33-4.

Reiche, P. (2). Keuchhusten und Influenza. Milnch. med. Wchnschr., 1920,
67, 1352.

Reiche, P. (3). Keuchhustenkrampfe. Ztschr. f. Kinderheilk., 1920, Orig. 25,
28-63.

Spolverini, L. Vaccinoprofilassi e vaccinoterapia della pertosse. Policlin.,
1920, Sez. Prat., 27, 1043-6.
Weill, E., et Dupourt, A. Traitement de la coqueluche par les injections

d'ether. Lyon med., 1920, 128, 562-3.

'^ J. D. E.

VACCINATION 205

VACCINATION

Reece points out that during the five years 1913-17, the number of
children vaccinated, as shown by the L.G.B. statistics, has continued to
decrease and the number of children exempted by statutory declaration has
continued to increase. The percentage vaccinated in 1917 was 43-3, and the
percentage exempted 37-9, while 12-0 per cent, of the children born in that
year were unaccounted for as regards vaccination. The circumstances of
the war had the effect of increasing the number of persons who had been
revaccinated, a very large proportion of the new army and a large propor-
tion of the women auxiliary workers having been revaccinated. It is there-
fore certain that at the present time a greater number of the male population
has been revaccinated than in previous years. Reece concludes that while
the adult population is better protected against small-pox than previously,
the proportion is unequally distributed between the two sexes, and that as
regards the child population only about half the children under 10 years
have been vaccinated.

According to the report of the chief medical officer of the Ministry of
Health, after deducting 44,693 deaths which took place before vaccination
among the 662,900 births reported by the several vaccination officers in
England and Wales during 1918, it appears that of the surviving 618,207
children 44-5 per cent, were registered as successfully vaccinated, 0-2 per
cent, as either insusceptible of vaccination or as having had small-pox, 1'9
per cent, as under medical certificate of postponement, and 40-3 per cent,
with certificates of conscientious objection to vaccination, leaving 13-1 per
cent, still unaccounted for as regards vaccination.

According to the vaccination returns for Bavaria for the year 1916,
which are quoted by Soucek, among 12,018 primary vaccinations and
157,577 revaccinations there were no primary infections of the vaccination
wound, and secondary complications occurred in only a very small number.
All the cases with any complications recovered without any sequelae.
During the first fortnight after vaccination a large number of cases of
primary vaccination and a few revaccinated cases developed intercurrent
diseases unconnected with vaccination, such as pneumonia, measles, diarrhoea,
and vomiting, convulsions, and Werlhof's disease, which were the causes of
death in 19 of the primary vaccination and 2 of the re vaccination cases.
Th6 mortality among the primary vaccination cases in the first year of life
was 3-9 per thousand, which was only a fraction of the mortality of the age-
group to which the cases of primary vaccination belong.

Groth reports that in 1917 the results of vaccination in Bavaria were
generally satisfactory. Of 116,171 children due to be vaccinated for the
first time 92,765 or 79-85 per cent, were vaccinated and 23,406 or 20-45 per
cent, remained unvaccinated, of whom 15,189 or 13-07 per cent, had
a medical certificate to justify abstention. Public vaccinators vaccinated
86,269 successfully, 1,302 unsuccessfully, and 147 with unknown result,
while private practitioners vaccinated 4,884 successfully, 160 unsuccessfully,
and 3 with unknown results. In addition 4,387 were vaccinated during the
first year of life, of whom 3,910 were vaccinated successfully, 188 unsuccess-
fully, and 13 with unknown results by the public vaccinators, and 259

IV. Q

206 REVIEWS

successfully, 16 unsuccessfully, and 1 with unknown result by private
practitioners. Out of a total, therefore, of 97,152 cases vaccinated for the
first time, 90,179 or 98-20 per cent, were vaccinated successfully, 1,490 or
1-62 per cent, unsuccessfully, and 160 or 0-18 per cent, with unknown
results by public vaccinators, and 5,143 or 96-62 per cent, successfully, 176
or 3-31 per cent, unsuccessfully, and 4 or 0-07 per cent, with unknown
results by private practitioners. Of 161,176 children due to be revaccinated,
157,794 or 97-90 per cent, were vaccinated, 3,382 or 2-10 percent, remained
unvaccinated, of whom 2,178 or 1-35 per cent, had a medical certificate.
154,912 or 98-65 per cent, were vaccinated successfully, 1,818 or 1-16 per
cent, unsuccessfully, and 295 or 0-19 per cent, with unknown results by
public vaccinators, and 702 or 91-29 per cent, successfully, 65 or 8-45 per
cent, unsuccessfully, and 2 or 0-26 per cent, with unknown results by private
practitioners. 12 of the primary vaccination cases and one of the re vaccina-
tion cases died. The causes of death in 5 cases was pneumonia, in 3
diarrhoea and vomiting, in 1 convulsions, in 1 diphtheria, and in 3, including
the revaccination case, the cause of death was not stated. The mortality
among the primary vaccination cases in the first year of life was only
3 per thousand.

Mensching states that owing to an outbreak of small-pox in Hamburg
in the late autumn of 1916 due to Wolhynian refugees (vide Medical Science,
1920, 3, 132), 684 new-born infants were vaccinated at the Hamburg
Obstetrical Institute between December 18, 1916, and July 14, 1917. The
vaccination was usually performed on the day of birth or the following day,
but never later than the third day. In 484 or 71 per cent, it was successful
and in 200 or 29 per cent, unsuccessful. The successful cases included 12
infants who had to be vaccinated twice. 18 infants failed to ' take' when
the vaccination was repeated. The percentage of unsuccesvsful vaccinations
was so high that it could not be attributed to deficient susceptibility to
vaccinia or to the avirulent character of the lymph, but was due either to
defective technique or to immunity acquired i)i utero. As a general rule
the course of vaccination in the new-born showed no difference from that
seen in older children vaccinated for the first time, typical vesicles occurring
which reached their fullest development on the seventh to eighth day after
vaccination. Severe constitutional disturbance hardly ever took place,
though a loss of 50-100 grm. a day lasting for two or three days was
frequently observed as the pocks reached their fullest development. In the
great majority of cases vaccination had no effect on the temperature, fever,
which is the rule in older children vaccinated for the first time, being quite
exceptional. In 42 infants in whom fever did occur the phenomenon in
most cases was due not to vaccination but to other factors. Among those
vaccinated at the Institute were 82 premature infants, in 52 or 64 per cent,
of whom the vaccination was successful, and in 30 or 36 per cent, unsuccess-
ful, so that the percentage of unsuccessful vaccinations was 8 per cent,
higher than in full-term infants. The local reaction was the same in the
premature as in the full-term infants, and the general condition in almost
all cases was not affected in any way.

Asregardsthevaccinationstate of the mothers, 281, withasingle exception
in which vaccination had taken place one year previously, had been vaccinated
during pregnancy and usually in the last three months. 339 were vaccinated
in the puerperium, in 6 vaccination was not performed, and in 58 no informa-
t/ion was available. It was found that the number of unsuccessful vaccina-

VACCINATION 207

tions was larger anioni;- the children whose mothers had been vaccinated in
pregnancy (Group I) than in those whose mothers had been vaccinated after
delivery or not at all (Group II). 173 or 61-6 per cent, in Group I were
successfully vaccinated, and 108 or 38-4 per cent, unsuccessfully vaccinated.
In Group II, 261 or 75-6 per cent, of the vaccinations were successful and
84 or 24-3 per cent, unsuccessful. The percentage of unsuccessful vaccina-
tions was therefore 14-1 per cent, higher in the children of the mothers
vaccinateil in pregnancy than in the othei'S. Mensching c^jnsiders it very
probable that the failure of vaccination in these children is due to an
immunity acquired in utero, especially- as it was found that on repetition of
vaccination' and control tests defective technique or bad lymph was not
responsible.

Teclinique. Goodall of Montreal recommends vaccination by sub-
cutaneous injection, which he has carried out in approximately 6,000 men
and a number of officers' children. From one-half to three-quarters of
a tube of vaccine is used per individual. Sufficient sterile water is then
added to make each injection equal to 1 c.c. The local reaction which
usually occurs in two or three days' time resemliles that following anti-
typhoid inoculation, and is as variable in intensit}'. About 8 per cent, were
negative. In 70 per cent, there was local swelling, heat, tenderness, slight
pain and redness. In a small percentage of cases the reaction was very
marked, causing swelling and oedema of the elbow, and in a few instances
oedema of the whole hand and arm. In every case the local condition sub-
sided without any signs beyond those of an intense local reaction. After
the seventh to tenth day the local swelling and induration subsided, leaving
a hard nodule in the subcutaneous tissue, usually ill-defined at first but
becoming later well circumscribed and lasting for about a month. The
advantages claimed for the method are as follows : (1) it is a clean surgical
operation. If untoward results develop, they are due to faulty technique ;
(2) there is no open wound and dressings are therefore not required ; (3)
dangers of secondary infection are practically eliminated ; (4) the percentage
of positive reactions is very high ; (5) in only a very small percentage did
the local and general symptoms cause complete incapacity : (6) the method
is painless as compared with scarification ; (7) children undergo it without
any difficulty, owing to the rapidity with which the injection is carried out.

During the last seven years, in which he has vaccinated over 500
children, Goldberger has used the inner and back side of the arm for
vaccination for the following reasons : (1) it leaves no visible scar ; (2) it does
not prevent children having their daily bath while vaccination is going
through its various stages ; (3) there is little or no exposure to infection
from outside sources of infection ; (4) it minimizes the sources of trauma ;
(5) no infiltration, extensive induration, sloughing, or extensive scarring
results. The method is as follows : after the arm has been cleansed
the forearm is flexed at right angles to the arm, and the vaccine is applied
below a line midway between the internal condyle of the humerus and the
anterior axillary line. The virus is allowed to dry thoroughly before
placing over the abrasion a sterile pad of gauze held in place by strips
of adhesive plaster.

King believes that the balance of evidence is in favour of lanolized
vaccine in respect to its resistance to tropical heat, and that as contrasted
with glycerinated and desiccated vaccine the risk of injurious influence upon
the virus is less. He gives the following comparative case success rates per

Q 2

208 REVIEWS

cent., as found in Uganda, of different forms of vaccine in 1916 : desiccated
vaccine (Lister Institute, London) 66 per cent. ; lanolized vaccine (Lister
Institute, London) 91-32 per cent. ; glycerinated vaccine (Nairobi) 67-32 per
cent. : arm to arm 78-09 per cent.

Complications. From examination of thousands of persons who had been
vaccinated or revaccinated, Gougerot has found that trichophytosis, although
very rare, is the most frequent complication of vaccination. Trichophytosis,
impetigo, and ecthyma, at the vaccination site were indeed the only skin
eruptions of any frequency observed by him. Examples of ulcerative
vaccinia, post-vaccinal eczema, psoriasis, and lichen were not seen. The
individuals affected were of all ages, viz. soldiers, workwomen in powder
factories, and children. The development of the lesions was usually slow.
The following varieties were seen: (1) single and round; (2) small and
oval ; (3) circinate ; (4) erythemato-squamous simulating psoriasis. The
practical importance of these cases is that if their nature is not recognized
they are improperly treated and do not heal.

At a recent meeting of the Section of Dermatology of the Royal Society of
Medicine, Pernet reported a case of post-vaccinal psoriasis in a girl aged 16,
in whom the eruption appeared two months after a primary vaccination,
while the scabs were still present on the vaccinated areas. The lesions first
appeared round the vaccination scars, and subsequently involved the elbows
and extensor surface of the forearms, hands, and knees. There was no
history of a rash before the vaccination. In the subsequent discussion
Dore remarked that j^soriasis sometimes occurred for the first time after
slight injuries, and that this might possibly explain its occurrence after
vaccination, and Fox reported the case of a medical man in Ceylon who had
never liad psoriasis before, but after revaccination developed psoriasis round
the points of inoculation, the eruption subsequently spreading down the arm
and eventually all over the body.

Wagner of Graz reports an unusual complication of vaccination in
a woman aged 36, who was subject to hay fever, and had been unsuccess-
fully vaccinated two years previously. On appearance of the vaccine pocks
she developed generalized oedema, asthmatic attacks, and a deposit on the
tonsils. Albumin (^ per 1,000) was found in the urine. As the lesions on
the arm subsided, all the other symptoms disappeared. Five other cases
among 30 who were vaccinated at the same time developed tonsillitis,
although there was no epidemic of sore throat prevalent. Deaths and
severe illnesses following vaccination were also reported at the same time
(July 1919).

Iyer records three cases of generalized vaccinia in Burmese children
aged 2-3 years, from which it appears that the condition depends on
personal idiosyncrasy, and not on climate, race, lymph, or the tube in which
it is contained.

King alludes to the liability of native races to certain skin eruptions,
and warns against hastily attributing their occurrence in the course of
vaccination to the impurity of the vaccine employed. Thus, in parts of
Africa during the hot season frequent instances of vesicular dermatitis and
impetigo having no connexion with vaccination are normally found, and
epidemics of ' pemphigus ' are said to have occurred, though possibly such
instances may have included the bullous form of impetigo contagiosa.

The development of phagedaena in the vaccine pustule towards the
third or fourth day of its evolution is described by Blanchard, at Grand-

VACCINATION 209

Bassam, Upper Guinea, who found a pure growth of the fuso-spirillar
symbiosis on microscopical examination of the serum from the periphery of
the lesions.

According to Naunyn, who has no doubt that there is a causal connexion
between the two events, jaundice may occur in epidemic form in adults
after revaccination. In such cases severe gastro-intestinal catarrh, shown
by vomiting and diarrhoea, often lasts for weeks before the appearance of
jaundice. The latter sets in suddenly, rapidly becomes intense, and lasts for
more than six weeks. The liver is not enlarged and there is no fever. Bile-
pigment is always found in the urine, but bile salts are not always present.
Slowing of the pulse, pruritus and xanthopsia have been observed. The
condition is never fatal. The most striking feature is the length of the
incubation stage. In none of 199 cases recorded has the jaundice appeared
earlier than two months after revaccination, and usually it has not developed
till much later, even as long as eight months.

BiiANCHABD. Complications phagedeniques de la vaccine. Bull. Soc. path,
exot., 1919, 12, 493-4.

GOZ.DBEBGEB, I. H. A uew site for small-pox vaccination. N. York M.J. ,
1920, 112. 1035.

GoODAZ.1., J. R. Vaccination by subcutaneous injection. Am. J. M. Sc, 1919,
158, 721-3.

GouoEBOT. Trichophyties post-vaccinales. Paris med., 1919, ii, 442-5.

Gboth, a. Bericht fiber die Ergebnisse der Schutzpockenimpfung in Bayern
im Jahre 1917. Miinch. med. Wchnschr., 1920, 67, 488-90.

Iter, S. R. Generalized vaccinia in Burmah. Indian M. Gaz., 1919, 54, 459-60.
King, W. G. Vaccination in the tropics. 1920.

Menschino, H. Beitrage zur Kuhpockenimpfung Schwangerer und Neuge-
borener mit Berucksichtigung der Frage einer intrauterinen Immunitatsiibertra-
gung. Arch. f. KinderheilL, 1920, 68, 24-48.

NAVismsi, B. Ueber Ikterus und seine Beziehungen zu den Cholangien. 3[itt.
a. d. Grenzgeh. d. Med. ic. Chir., 1919, 31, 538-600.

Pebnet, G. Case of post-vaccinal psoriasis. Proc. Boy. Soc. Med., 1921, 14,
Sect, of Derm., 12.

Beece, R. J. Vaccination and Government lymph establishment. Annual
Bep. Local Gov. Bd., 1918-19, 48, Med. Supplement, 151-4.

SoucEK, A. Pocken und Pockenimpfung. Wien. med. Wchnschr., 1919, 69,
2341-6.

Vaccination. Blinistry of Health, Annual Bep. of Chief Med. Off., 1919-20,
1920, 1, 220-5.

Waoneb, K. Beobachtungen uber die Blatternimpfung. Wien. hlin.
Wchnschr., 1919, 32, 1186-7.

J. D. R.

210 REVIEWS

GONORRHOEA

Aetiology. The differences in toxicity of different strains of gonococci
have been investigated by Jotten. By means of the methods of agglutination
and complement fixation used to differentiate the several forms of meningo-
cocci, he was able to separate four groups of gonococci which he terms A, B,
C, and D. The groups A and B were found to be more toxic for mice than
groups C and D and the non-classified gonococci, and to possess greater
resistance to the opsonic, bacteriotropic and bactericidal action of normal
serum. It was also found that these groups were associated with severe
and complicated cases of gonorrhoea in the human subject. No morpho-
logical or cultural differences between the more toxic and less toxic forms
were discovered. Jotten remarks that these results show the importance of
using autogenous vaccines, and explain the unsatisfactory results obtained
by stock vaccines, which often do not contain the strain corresponding
to that in the patient.

The two questions Lomholt has attempted to answer by a study of the
548 cases of recent venereal disease in men attending a free dispensary in
the period October 1, 1916-May 1, 1920 are these: (1) What proportion of
infections of men can be traced to professional prostitutes, i. e. women who
receive cash down? (2) What proportion of infections occur under the
influence of alcohol 1 Lomholt found his informants remarkably candid.
Most of them (476) suffered from gonorrhoea, the short incubation period of
which renders it more suitable for investigating these two problems than is
the case with syphilis. In 153 cases, i. e. 28 per cent., infection was traced
to professional prostitutes. As Lomholt points out, this ratio is much lower
than Fournier has found to be the case in Paris or Blaschko in Berlin, the
corresponding figures for these two towns being 72 per cent, and 81 per cent,
respectively. Lomholt argues from his figures that brothel prostitution is
dying out in Copenhagen, and is giving place to a Itess systematic and more
human form of casual sexual intercourse. While only about one-quarter of
all the cases of gonorrhoea and syphilis could be traced to professional
prostitutes, they were responsible for half the cases of chancroid, the com-
parative frequency of which is greatest when the conditions of sexual
intercourse are most degraded.

Of the 455 men questioned as to the influence, if any, of alcohol,
217 had taken the alcohol equivalent of two half-bottles of beer or more at
the time of infection. In about three-quarters of these cases the men
admitted to having been drunk. Thus, 48 per cent, contracted venereal
disease under the influence of alcohol, and of the men infected hy professional
prostitutes, 75 per cent, -were under the influence of alcohol. On the other
hand, only 37 per cent, of the men infected by other than professional
prostitutes had taken alcohol. The difference clearly shows that alcohol
lowers the standard set by men in their choice of bed-fellows. In 72 cases,
or 13 per cent, of the total, the men were married, and as many as 36,
or 50 per cent., were infected by professional prostitutes. The propor-
tion of drunkenness was also much greater among the married than the
unmarried.

Symptomatology. A case of gonococcal se'pticaeniia, in which the

GONORRHOEA 211

gonococcus was found in the blood and also in the sputum, is reported by
Ribierre and L^obardy. The septicaemia developed a mouth after ^ono-
rrhoeal urethritis, which still persisted. A Gram-neoative diplococcus was
cultivated by the addition of 20 c.c. of blood, withdrawn during pyrexia, to
a bouillon-ascites medium. Signs of pulmonary consolidation appeared at
the right apex, with blood-stained expectoration. Examination of the
sputum was negative for tubercle bacilli and for pneumococci, but positive
for Gram-negative diplococci. As the pulmonary signs underwent resolu-
tion, and the diplococci were morphologically identical with gonococci, the
authors conclude that the case was one of gonococcal septicaemia with
a pulmonary metastatic complication.

A case of gonococcal septicaemia com'plicated by icterus is reported by
Widal and May. As they remark, icterus may develop in the course
of many infections, but is rare in gonorrhoea. The few cases hitherto
recorded appear to have been all fatal. The case reported by these observers
was severe, but was cured by five intravenous injections of antigonococcal
serum, diluted 1 in 10. It is noted that beneficial effects with this serum
have been obtained in gonorrhoeal arthritis, and the serum is recommended
in all cases of general gonococcal infection, administered either intravenously
or intramuscularly.

Jagic and Schiffner are of opinion that gonococcal infection of the heart
is more frequent than generally supposed, and that if more attention was
paid to the heart in cases of general gonococcal infection, more instances
would be discovered, especially of the milder forms of myocarditis. They
also think that gonorrhoea may account for some cases of myocarditis
of obscure aetiology. They point out that endocarditis, which is the most
common form of gonorrhoeal infection of the heart, may be vegetative or
ulcerative. Vegetative endocarditis may be the only localization of general
gonococcal infection, is more common than the ulcerative form, affects the
mitral valves generally, and often leads to mitral insufficiency. The ulcera-
tive form generally affects the aortic valves and runs the course of pyaemia.
Myocarditis of gonorrhoeal origin, they remark, is not so well recognized.
They distinguish two forms : (1) acute septic myocarditis, resulting in
multiple abscesses in the myocardium, and generally resulting in pyaemia ;
(2) simple infective myocarditis. The latter, which is a rare condition, must
be distinguished from functional cardiac symptoms of a vasomotor nature
occurring during a period of pyrexia. Clinically, simple gonorrhoeal myocar-
ditis is characterized by cardiac weakness, arhythmia, dilatation of the
left ventricle, and mitral insufficiency. It may end in resolution or result in
fibrosis. Two illustrative cases are given, both occurring in women, one
compHcating gonorrhoeal urethritis and arthritis, the other gonorrhoeal
salpingitis. In both cases the cardiac signs appeared after resolution of the
pyrexia and acute inflammatory local conditions, and in both there were
signs of myocarditis with dilatation of the left ventricle.

While endocarditis is common in children in connexion with rheumatism
and chorea, gonococcal endocarditis as a complication of vulvo-vaginitis
appears to be rare. A case of malignant eiulocarditis due to the gonococcus,
in a child aged 23 months, is reported by Dwyer. The symptoms included
a vaginal discharge, pain and swelling of the left ankle and wrist, some
degree of anaemia and jaundice, abdominal distension, and a temperature of
104° F. The cardiac signs consisted in a rapid and irregular pulse, and
a soft, systolic murmur at the apex conducted to the axilla. There was also

212 REVIEWS

a superficial abscess over the lumbo-sacral region. Microscopic examina-
tion of the vaginal discharge showed Gram-negative intracellular diplococci.
The same were found in the pus from the lumbo-sacral abscess. Blood
culture on ascitic glucose broth and ascitic glucose agar resulted in a growth
of the same diplococcus (gonococcus). The child died on the twenty-eighth
day of her illness. The autopsy showed cauliflower vegetations on the
mitral valve, in which gonococci were found. The other valves were normal,
and there was no pericarditis. There was no evidence of peritonitis. The
lumbo-sacral abscess was attributed to localization of gonococci from the
blood-stream due to lowered resistance in the area from pressure, a condition
analogous to a bed-sore. The case is of interest on account of the age of the
patient, the cultivation of the gonococcus from the blood, and the rarity of
gonococcal endocarditis in children. Satterthwaite is quoted as having
found only one case in a hundred, and Dunn as having found none of
gonococcal origin in 304 cases of endocarditis in children.

Strandberg and Hedenius report a case of chronic gonorrhoeal arthritis
compKcated by keratodermia bleiiorrhagica. The patient, a male aged 26,
had three attacks of gonorrhoea in the course of four years. The first
attack was complicated by arthritis of the knee, which recurred during the
later attacks, and eventually affected the shoulders, wrists, and cervical
vertebrae. The cutaneous lesions commenced six years after the first and
two years after the last attack of gonorrhoea. They were situated on the
lower part of the right leg and ankle, the upper part of the left leg
and knee, and on the right hand. Microscopic examination showed changes
similar in nature to those described in other cases of gonorrhoeal hyper-
keratosis. The patient died from cachexia the following year.

The authors remark that keratodermia blenorrhagica occurs, as a rule,
in cases of severe gonorrhoeal infection complicated by multiple arthritis,
bad general condition, and cachexia. The cutaneous lesions generally affect
the lower extremities, are of an inflammatory nature, and characterized by
a predisposition to parakeratosis, manifested by the formation of thick,
horny patches. In many cases there is also present a hyperkeratosic balan-
itis. Although the affection occurs in association with gonorrhoea, it may
be partly due to secondary infection. The names keratodermia or hyper-
keratosis are inexact, the lesions being more of the nature of a parakeratosis.

Adamson draws attention to the resemblance between this affection and
arthropathic psoriasis of the palms and soles, and points out that in many
cases of gonorrhoea] hyperkeratosis there are lesions of the trunk which are
indistinguishable from psoriasis. He suggests that psoriasis may possibly
be due to a microbe allied to the gonococcus.

Diagnosis. Magner reports his experience with the complement-jixatio n
test in gonorrhoea. The technique employed was similar to Thomson's ; the
antigens tried were Thomson's and Parke Davis & Co.'s ; the complement
was obtained from guinea-pig serum ; the haemolytic system consisted of
haemolytic serum, prepared by Burroughs Wellcome & Co., and sheep's cells.
The patients' serum was heated to 60° C. for ten minutes and then diluted.
200 cases were examined, 110 gonorrhoeal and 90 control. In the gono-
rrhoeal cases, the test was generally negative up to 10 or 12 days after
infection, afterwards most cases were positive; but some mild cases in
which the urethritis was limited to the anterior urethra were negative.
The longer the duration of the discharge the more often is a positive result
obtained. The complications of gonorrhoea, such as epididymitis and gono-

GONORRHOEA 213

rrhoeal rheumatism, were always positive. A positive reaction was obtained
for three months after gonococci were absent, so that the reaction is no test
of cure till three months without treatment have elapsed since the last
symptoms.

Magner regards the test as useful in the diagnosis of cases which are
negative microscopically. A positive result shows either that gonococci are
still present, or that the antibodies they give rise to are still present in the
serum. A negative result, especially after a previously positive one, is
strong evidence of a cure. The administration of an autogenous gonococcal
vaccine did not appear to prolong the positive stage to any great extent.
The control" cases were all negative, except four, all of which were sj^philitic.
and so might have been infected with gonorrhoea as well.

The difficulty in diagnosing gonococcal infections by cultural methods,
and the uncertainty of the complement-fixation test, led Robinson and
Meader to apply a preci'pitiii test, similar to that used in pneumococcus and
meningococcus infections. For this purpose they tried the reaction of
immune rabbit serum and the autolysate of gonococcus cultures. Their
method is described as follows : Rabbits were injected intravenously with
single strains of gonococci in gradually increasing doses at seven-day
intervals. Five or six injections were generally sufficient to produce a serum
giving a marked precipitin reaction in a dilution of 1 in 20. The autolysate
was prepared by washing otf the growth of gonococci on rabbit blood agar
in 5 c.c. of normal saline solution and allowing it to stand in an incubator
for six hours. This suspension was centrifuged, and the supernatant fluid
superposed on an equal quantity of the immune serum. The tubes were
then placed in a water bath at 37° C. for one hour. After cooling, the results
were read. A positive reaction was indicated by a cloudy-white ring at the
junction of serum and autolysate. All strains of gonococci gave a positive
reaction with immune serum, and no differences were noted between homo-
logous and heterologous autolysates, so that there appeared to be no strain
specificity.

For purposes of diag-nosis the autolysate is obtained by moistening
a sterile SAvab in the material to be tested and incubatincr in 2 c.c. of normal
saline solution for six hours. The swab is then removed and the infusion
centrifuged. If, as occasionally happens, the fluid remains opalescent in
spite of centrifugalization a correct reading can be obtained by comparing
density of the precipitated ring with that of a control tube containing
normal rabbit serum.

The procedure is described as follows : For each specimen to be
examined 0-25 c.c. of diluted clear serum from two immune and one
normal rabbit are placed in test-tubes. The clear extract of the speci-
men is superposed on an equal amount of serum. The tubes are incubated
for one hour at 37° C. and allowed to cool. Two immune sera are used in
order to duplicate the results, and the serum from a normal rabbit is used as
control.

The authors found that some sera gave a false reaction when saline
solution was added, but obviated this difficulty by diluting the serum with
saline (one to two) and centrifuging till clear. From their researches, they
conclude : (1) that a positive precipitin test is obtained in all cases where the
gonococcus is found in the discharge ; (2) that it is also obtained in many
cases where the history and symptoms point to gonorrhoeal infection, but in
which the gonococcus cannot be found in the secretion ; (3) that the test is

214 REVIEWS

of value in the diagnosis of vaginal and other specimens where the micro-
scopical demonstration of gonococci is difficult or impossible.

It is interesting to note that the meningococcus gave a positive reaction
with gonococcus immune serum when a concentrated pure culture autolysate
was used, but the gonococcus control autolysate continued to give a positive
reaction for a considerable number of dilutions after the reaction with the
meningococcus had become negative. Micrococcus catarrhalis, B. coli, and
all other organisms tested gave negative reactions.

Treatment. Miiller, having observed that concomitant gonorrhoea was
improved in patients under treatment for sycosis by intramuscular injections
of turpentine and ' aolan ' (a trade name for a sterilized solution of milk
albumin), tried the same treatment in cases of gonorrhoea. These substances
are said to have a beneficial effect in staphylococcal infections. The conclu-
sions arrived at were : that the duration of acute anterior urethritis was
shortened to a period of three weeks ; that acute posterior urethritis subsided
after two or three injections, so that local treatment could be carried out ;
that chronic posterior urethritis was also benefited ; tliat complications were
less frequent, and that both drugs were useful in epididymitis. The dose of
turpentine was from 0-5 to 1-0 c.c. given at intervals of three or four days;
that of ' aolan ' from 6 to 7 c.c. In cases of cystitis and pyelitis, Muller
recommends intravenous injections of 0-15 to 0-30 grm. neosalvarsan, which
he thinks acts hy the formaldehyde contained in it.

The results of the treatment of gonorrhoeal arthritis by a non-specific
protein (usually Bacillus typhosus) have led to further experimental injec-
tions. Stern and Ritter state they have found the intravenous injection of a
solution of sodium iodide to produce undoubted benefit in cases of gonorrhoeal
arthritis, epididymitis, and prostatitis. Both acute and chronic conditions
are benefited. The results observed are claimed to be not less than those
following the injection of a non-specific protein. The authors observe that
the efficacy of the latter form of treatment appears to be dependent upon
the production of leucocytosis and a marked febrile reaction. Sodium iodide
produces no alteration in the blood-count, and no reaction effects at all ; the
injections may therefore be employed without hesitation in the treatment of
out-patients and in the private consulting-room. The drug was administered
in doses of 2 grm. dissolved in 20 c.c. of water, and the injections were repeated
every four days. All the usual therapeutic measures were employed in con-
junction with intravenous medication. One hundred cases have been discharged
' germ-free ' and apparently cured ; the authors estimate that the average
stay in hospital of these patients has been reduced by one-third owing
to this additional treatment.

Gonorrhoea in the female. In 3,439 examinations of prostitutes
Stevens and Heppner found chronic gonorrhoea in 43*5 per cent. The
cervix was affected in 47, the urethra in 32, and one or both Bartholin's
glands in 23 per cent, of the cases. The complement-fixation test was posi-
tive in 59 per cent, of cases of cervical infection, in 23 per cent, of urethritis,
and in 19 per cent, of bartholinitis. In the treatment of endocervicitis good
results were obtained from the application of a 25 percent, solution of silver
nitrate twice weekly in conjunction with hot vaginal douches. Better results
were obtained by cauterization of the cervix. In urethritis gonococci were
found in about one-third of the cases : other organisms present in order of
frequency were Gram-positive diplococci, staphylococci, streptococci, diplo-
bacilli, and other bacilli. The importance of examining Skene's and other

GONORRHOEA 215

glands near the meatus, which are usually attected in gonorrhoeal urethritis,
is pointed out. In the absence of complications acute urethritis in the female
usually clears up with sandalwood oil, alkaline drugs, and rest in bed.
Chronicity was generally due to glandular infection or stricture. Strictures
at the meatus or within the urethra were found in 58 per cent, of the cases.
The treatment adopted consisted in instillations of 1 to 3 per cent, solutions
of silver nitrate, and application of stronger solutions through a short endo-
scopic tube. AcriHavin and mercurochrome proved of little value. Infected
glands and ducts were destroyed by the cautery and strictures were dilated
or incised. . With regard to Bartholin's glands, the authors point out that
a normal gland is usually impossible to palpate, and that a palpable gland
generally means infection. Treatment by injection of various solutions
proved of little or no value, and the authors recommend excision of the
gland both in acute and chronic cases.

As Rawlins points out, in the treatment of gonorrhoea in women,
the results will be disappointing if care is not taken that no infected part is
overlooked, such as Bartholin's and Skene's ducts. Infection of these ducts
is connnon and persistent, and also of the urethra. The ducts can be washed
out with a syringe and blunt-pointed needle, and if this fails the duct can be
incised and treated with iodized phenol or destroyed by the electric cautery.
Urethritis usually clears up with local application of picric acid and internal
urinary antiseptics. According to Rawlins, the most satisfactory drug for
local treatment is 50 per cent, picric acid in glycerine, applied by swabbing
to the vulva, vagina, and cervix two or three times a week. Sauerin
pessaries were also found useful. Douching is not recommended unless the
tubes are affected, when the warmth of the douche is beneficial. A douche
at high pressure, performed by the patient herself, is considered liable
to cause spreading of the disease to the uterus. If douching is done, the
patient should lie on her back with the buttocks slightly raised, and
the douche-can not more than 1^ feet above the level of the body.

Jacoby recommends the following treatment. During the acute stage
of urethritis, rest in bed, hyoscyamus and sandalwood oil. After the acute
urethritis has subsided, urethral injections of 1 per cent, protargol or 20 per
cent, argyrol every other day. In chronic cases, instillation of ^ per cent,
protargol or 1 in 10,000 silver nitrate into the bladder three times a week ;
the application of 5 per cent, silver nitrate to ulcerated areas of the urethral
mucous membrane through a speculum ; injection of Skene's tubules with
10 per cent, silver nitrate daily, or, in obstinate cases, cauterization. Of
the more recent [remedies, 1 per cent, acriflavin or mercurochrome give
promising results as a urethral injection. In acute endocervicitis, similar
treatment to that for acute urethritis. In subacute and chronic endo-
cervicitis, the application of 25 per cent, argyrol or 1 per cent, protargol to
the cervical canal, followed by glycerine and packing the vagina with gauze
three times a week. The packing is removed after 18 hours and followed
by douches of permanganate of potash 1 to 5,000, tincture of iodine 1 to
500, acriflavin or mercurochrome 1 to 5,000. Gonococcal vaccine, 500
millions every five days is useful in chronic cases. In the treatment of
complications conservatism is advised, operation being only resorted to
when unavoidable.

Before a case is discharged as cured, Jacoby insists on the following
conditions being fulfilled : (1) Smears from the cervix, urethra, Skene's and
Bartholin's glands, some taken just before and some just after menstruation,

216 REVIEWS

should be negative on six occasions ; (2) smears after provocative injection
of the urethra should be negative ; (3) the complement-fixation test should
be negative ; (4) all these tests should be negative when repeated a month
after cessation of treatment.

Having previously obtained good results from the treatment of certain
gonorrhoeal complications, such as arthritis and epididymitis, by intravenous
injections of arsenical compounds, Levy-Bing and Duroeux have tried this
method of treatment in cases of acute gonorrhoeal salpiagitis, with equally
beneficial results. In these cases the arsenical preparation used was
sulpharsenol, administered in doses of 0*06 up to 0*18 grm. at intervals of
two or three days. In one case, where a woman was confined to bed with
repeated metrorrhagia, high temperature, anaemia, and pain, the haemo-
rrhages ceased, the pain subsided, and the patient was able to get up within
a week after the first injection. Bimanual vaginal examination also showed
subsidence of the pelvic inflammatory condition. Three cases of chronic
relapsing salpingitis, treated in the same way, were also reported cured
in a few weeks.

Borland advocates the local application of raethylene blue, 1 per cent.,
in the treatment of gonorrhoea in women. The advantages are said to be —
powerful gonococcicidal action, absence of irritation, rapid relief of clinical
symptoms, and disappearance of gonococci after six to twelve applications.
According to Dorland, methylene blue, which was used some years ago in
the treatment of gonorrhoea, was chiefly administered internally, and was
abandoned because it appeared to undergo some change in the body which
rendered it inert. As a local application, however, he considers it superior
to those in general use.

Although the value of serum treatment in gonorrhoea has been
questioned on the grounds that the gonotoxin is an endotoxin, and, therefore,
to be attacked by vaccines instead of serums, several observers have
reported good effects from the use of antigonococcal serum. Ivens has
tried antigonococcal serum in 30 cases of gonorrhoea in women, in 22 of which
tubal infection was present. The serum used was Nicolle's, prepared at the
Pasteur Institute, and was administered in three different ways. In one
series of cases the serum was injected subcutaneously, usually in doses of
20 c.c. diluted with normal saline, repeated at intervals of 2 to 3 days. In
another series intraperitoneal injections were given. In cases of pyosalpinx
the tube was washed out with normal saline, after being opened up if
necessary. The serum was injected into the tubes, sometimes into the
ovary, and the abdomen was then closed without drainage. A subcutaneous
or rectal saline was given at the same time to avert anaphylactic shock. In
a third series of cases of endocervicitis with profuse leucorrhoeal discharge
the serum was used locally in the form of vaginal packs, alternating daily
with packs of 10 per cent, saline solution and 5 per cent, carbolic acid.
Intravenous injections of serum were not used, on account of the danger of
anaphylactic shock. Of the 30 cases, subcutaneous injections were used in
19, intratubal and intraperitoneal in 6, vaginal packs in 3, and serum dressings
in 2 cases of bartholinitis. In all the cases the immediate results were good,
and the after-histories satisfactory in most cases. Three cases relapsed, one
possibly owing to insufficient serum being used, the other two probably
from reinfection. In the intraperitoneal cases the results were much better
than in cases where no serum was given at operating, and in one case preg-
nancy was proceeding normally.

GONORRHOEA 217

As Daken remarks, gonorrhoeal vulvovaginitis in children is obstinate,
owing to the foci of the disease being difficult of access and to the frequency
of involvement of the cervix. For this reason clinical symptoms may clear
up under treatment and relapses occur subsequently. He mentions a case,
a girl aged seven, in which the bacteriological examination became negative
after treatment with urinary antiseptics, vaginal irrigations, protargol
pessaries, sitz baths, and diathermy. After provocative injections of Lugol's
solution and ' aolan ' (milk albumin), however, gonococci were again found
in the secretion. The case was eventually cured with vaccines (arthigon).
As a test of cure, therefore, he recommends— after cessation of treatment
and negative bacteriological examination for ten days— provocative injections
of Lugol's solution and ' aolan ', repeated after a week and again after two
weeks. If still negative for gonococci after this procedure the case may be
considered cured.

Patzschke recommends the addition of adrenalin hydrochloride to the
silver solutions used for irrigation in the treatment of vulvovaginitis in
children. By the action of the adrenalin on the hyperaemic mucous
membrane it is claimed that stronger solutions of silver preparations can be
used. The method of treatment is as follows : after cleansing the vulva,
the vagina is injected with weak permanganate solution, which is retained
for five minutes by closing the labia. A tampon soaked in 5 per cent,
protargol solution is then placed in the vulva. Irrigations four times a day
are then performed, commencing with 0-5 per cent, albargin solution, to
which is added 1 in 1,000 adrenalin solution (0-5 to 2 in 20). After three
or four days the strength of albargin is increased to 1 per cent., and in ten
days up to 2 per cent. After a fortnight the irrigations are done once
a day only, and a smear is tested for gonococci. If the result is negative
the treatment is continued for another ten days. If again negative 24
hours after cessation of treatment, the irrigations are discontinued. In 1 1
cases treated in this way there were only two relapses.

Adamson, H. G. Keratodermia blenorrhagica : is it a form of psoriasis ?
Brif. J. Bermat. 4- Syph., 1920, 32, 183-7.

Daken, J. Zur Beurteilung der Vulvovaginitis gonorrhoeica im Kindesalter.
Miinchen. med. WcJmschr., 1920, 67, 1172-3.

D0BI.AND, N. The problem of the efficiency of topical applications of methy-
lene blue in female gonorrhoea. Med. Bee, 1920, 98, 268.

DwYER, H. L. Malignant endocarditis and metastatic abscess in gonococcemia.
J. Am. 31. Ass., 1920, 75, 1643-4.

IvENS, F. A note on the use of antigonococcal serum. Brit. 31. J., 1921, i,

77-8.

Jacobt, a. Gonorrhoea in women. 31ed. Becord, 1921, 99, 14-16.

Jagic, N., u. Schiffneb, O. Uber gonorrhorische Herzerkrankungen. 3Ied.
Klin., 1920, 16, 976-8.

JOTTEN, K. W. Beziehungen verschiedener Gonokokkenarten zurSchwere der
Infektion. 3Iunchen. med. Wchnschr., 1920, 67, 1067-9.

Li;vY-BiNO, A., et DuBOEUX, L. Traitement des salpingites aigues d'origine
blennorrhagique par les injections intraveineuses de sels d'arsenic. Ann. d. mal.
ven., 1920, 15, 529-34.

218 REVIEWS

L0MH01.T, S. Prostitution, alkohol og venerisk sygdom. Ugesk. J. Lccger,
1920, 82, 950-4.

Magneb, W. The complement-fixation test in gonorrhoea. Lancet, 1920, ii,
123-5.

MuiiiiEB, H. Hilfstherapie der Gonorrhoe. Med. Klin., 1920, 16, 955-6.

Fatzschke, W. Zur Thei'apie der Vulvovaginitis gonorrhoica infantum.
Deutsche nied. Wchnschr., 1921, 47, 44-6.

Rawliits, M. a few points in relation to the treatment of venereal diseases in
women. Brit. M. J., 1920, ii, 194-6.

RiBiEBBE, P., et Leobabdy, J. de. Septicemie gonococcique avec congestion
pulmonaire. Bidl. et mem. Soc. med. d. hop. de Par., 1920, 3^ ser., 44, 862-4.

ROBiirsoir, G. H., and Meadeb, P. D. The precipitin reaction in the dia-
gnosis of gonococcus infections. /. Urol., 1920, 4, 551-8.

Stebzt, M., and Ritteb, I. S. A new method of treating remote manifesta-
tions of gonorrhoea! infections. Med. Bee., 1920, 97, 190-1.

Stevens, W. E., and Heppneb, M. Gonorrhoea of the lower genito-urinary
tract in women. -J. Am. M. Ass., 1920, 75, 1477-9.

Stbandbebg, J., et Hedenius, J. Gas d'arthrite gonorrheique avec altera-
tions caracteristiques de la peau. Contribution a la question de la keratodermie
gonorrheique. Ark. f. inn. med., 1919, 51, 521-50.

WiDAii, P., et May, E. Un cas d'ictere infectieux a gonocoques.
Soc. med. d. hop. de Far., 1920, 3^ ser., 44, 1076-80.

Bull

mem.

M..

CHANCROID

According to Cheinisse, chancroid and its complications are more common
than is generally supposed. Out ot" a total of 235 primary sores observed
at the General Hospital at Rouen, 61 were syphilitic, 125 chancroid, and 49
mixed; and out of a total of 155 primary sores observed at a military
venereal centre 89 were syphilitic, 64 chancroid, and 32 mixed.

Symptomatology. That all genital sores diagnosed as ulcus molle, or
chancroid, are due to the bacillus of Ducrey is doubted by McDonagh. He
also casts doubt on the usually accepted doctrine that a chancroid frequently
develops into a syphilitic chancre owing to double infection. In such cases
he regards the initial diagnosis as incorrect.

The varieties of ulcus molle described by McDonagh are : (1) ulcus
molle elevatum,, in which the sore is raised and often indurated, rendering it
liable to be mistaken for a syphilitic chancre ; (2) ulcus molle milicire,
resembling hair follicle infection and more common in w^omen ; (3) ulcus
molle phagedaenicum, which he regards as less common than phagedaenic
sj^philitic chancre, and due to the symbiosis of fusiform bacilli and spiro-
chaetes similar to those found in Vincent's angina and balanitis gangrenosa;
(4) ulcus m,olle serpiyitiosum. This last variety he considers to be more

CHANCROID 219

common than generally supposed, and to be usually wrongly dia<:^nosed.
This variety resembles a furuncle, the edges of which become blue and
break down into an ulcer. The base of the ulcer is uneven and secretes
freely ; the edges are ragged and undermined, the overhanging portions
being oedematous and bluish-white in colour. The periphery of the lesion
is of a purple colour and is surrounded by a red zone of inHannnation. The
ulcer spreads at one part while the opposite part is healing, and the lesion
may gradually progress for years. In a case described by ]\IcDonagh the
lesion spread from the groin up to the umbilicus and down to below the right
knee in the course of 27 years. Ducrey's bacillus was found intraccUularly
in this case. Ulcus molle ser]iiginosum is thus a very chronic form of
ulceration following a chancroid, and occurs chiefly among people who have
lived in the tropics. In some cases it develops from a bubo after the
original sore has healed.

Diagnosis. Teague and Deibert point out that the difficulty in diagnos-
ing chancroid from microscopical examination of smears is due to the fact
that the bacillus of Ducre}' in passing from the tissues into the purulent
discharge loses its characteristic arrangement in long chains and appears in
the form of small pleomorphic bacilli, from which it is unsafe to make
a definite diagnosis. They therefore tried the method of adture, from
which they report successful results. The medium used for culture was
rabbits' blood allowed to clot at room temperature, then heated for five
minutes at 55° C, and either used at once or kept in the ice-chest overnight.
Tubes of this medium were inoculated with pus from the sore to be examined,
and after 24 hours' inculcation at 37° C. the serum showed characteristic
chains of the small Gram-negative bacillus of Ducrey, sometimes apparently
in pure culture, sometimes mixed with Gram-positive cocci and bacilli.
Positive results were often obtained after the application of antiseptic
ointments, &c. Previous washing with sterile salt solution was found
unnecessary. Human blood was tried for culture, but found inferior to
rabbits' blood.

By this method, Teague and Deibert examined 274 sores situated on
the penis. As they obtained a positive result in more than 50 per cent.,
and as most of the negative cases showed no clinical evidence of chancroid,
they conclude that a diagnosis of chancroid can be made in probably over
90 per cent, of cases by the method of culture. The}^ attribute the failure
of the cultural method in other hands to the use of unsuitable media. The
bacillus of Ducrey does not grow on any of the ordinary media except
blood agar, and on this with difficulty.

Treatment. Cheinisse reviews the various methods of treatment
which have been tried, including : (1) filiform drainage conibined with
dressings of permanganate of potassium 1 in 200 ; (2) incision, followed by
the application of a Bier's cup for ten minutes, and then injections of iodo-
form emulsion ; (3) Goubeau's method, by injection of a 1 per cent, solution
of arseniate of sodium before softening has occurred. In this method, if
suppuration has occurred, the pus is evacuated by a small trochar and 1 or
2 c.c of the arseniate solution mixed with 0-5 c.c. of ether is injected ; the
ether, becoming gaseous at body temperature, distends the abscess cavity and
allows more complete contact with the solution. The injections, are made
daily or every other day ; (4) Lasserre's emulsion for injection, consisting of
10 parts each of iodoform, guaiacol, eucalyptol, and alcohol, 30 parts of balsam
of Peru, and 100 parts of ether.

220 REVIEWS

Cheinisse also mentions that a favourable influence on the evolution of
chancroidal bubo was obtained by Kurita, a Japanese surgeon, by means of
a vaccine prepared from the bacillus of Ducrey.

Reenstierna claims good results from the use of a serum obtained from
rams after intravenous injections of killed and living cultures of Ducrey 's
bacillus. In 100 cases of chancroid with bubo the sores are said to have
healed and the buboes to have subsided in a week, after two injections of
10 c.c. of this serum. It is also stated that the serum had no effect on cases
wrongly diagnosed as chancroid.

McDonagh recommends cauterization by camphphenol or by zinc
ionization, followed by the application of a dusting powder consisting of
equal parts of bismuth subgallate, bismuth tribromphenolate and light
magnesium carbonate, mixed with starch. In chronic sores he gives two
intramuscular injections of intramine, followed by two intramuscular in-
jections of ' trimine ' (a colloidal mixture of manganese, iron, and zinc),
also a local dressing of intramine. The sores should be exposed to the
air and not covered with air-tight dressings. In cases of sores con-
cealed by a tight prepuce the latter should be slit up, but no other operative
measure should be carried out, as the wounds always become infected and
phagedaena often results.

In the treatment of bubo, incision should be postponed as long as
possible ; many cases subside under evaporating lotions, such as a mixture
of subacetate of lead, strong solution of ammonia, rectified spirit and acetate
of alum. If an incision is necessary it should be a small one ; a long
incision leads to infection of the interglandular tissue, leaves a wound wliich
takes a long time to heal, and may result in phagedaena. Puncture with
a bistoury, expression of pus, washing out with saline solution, and dusting
with the powder mentioned above are sufficient. According to McDonagh,
buboes may be aborted or rapidly healed by intramuscular injections of
'trimine' and intramine. In cases of ulcus molle serpiginosum. operative
measures are contraindicated. McDonagh recommends colloidal iodine
internally (three drachms thrice daily), and intravenously (100 c.c.) followed
in two days by an intramuscular injection of intramine (3 c.c), repeated
five days later and followed by one to three injections of trimine or an anti-
mony salt. Locally, camphphenol and iodoform or intramine. The chronic
case of 27 years' duration already mentioned, which had resisted all the
usual forms of treatment, is said to have healed under local applications
of intramine, intravenous injections of tartar emetic and intramuscular
injections of intramine.

Golay recommends Fontan's method of treating chancroidal buboes in
suitable cases. This method consists in making a small puncture with
a bistoury, evacuation of pus, injection of 10 per cent, iodoform vaseline, and
sealing the puncture. After 48 hours the vaseline is evacuated. In
favourable cases cure is said to take place in four or five days. According
to Golay this method is successful under certain conditions which are briefly
as follows : (1) The bubo must be completely softened. If there is
a tendency for the pus to point before the gland has completely softened it
is better to open freely and curette, because the method of Fontan will only
express the pus of the periadenitis and leave that in the gland which will
form a fistula afterwards. (2) There must be no involvement of the skin by
the bacillus of Ducrey ; this requires energetic cauterization. (3) There
must be no burrowing of pus, as Fontan's method will not distend the

CHANCROID 221

pockets. (4) The essentials for success are complete expression of all pus
and distension of the cavity with the same amount of iodoform vaseline as
the pus evacuated. The vaseline should be heated and then cooled to the
right consistency. Tiic patient should remain in bed for 48 hours.

Cheinisse. Traitement des Inibons chancrelleux. Presse mcd., 1920, 28
285-6.

GoLAT, M.J. Le traitement des bubons chancrelleux par le precede de Fontan.
Eev. med. de la Suisse Horn., 1920, 40, 485-93.

McDoNAGH, J. E. R. Venereal diseases ; their clinical aspect and treatment.
1920, 261-71.

Reenstiebna, J. The serum treatment of chancroid. Fork. Svcns. Laic-
SalUk. Sammanh, 1920. [Lancet, 1920, ii, 144-5.)

Teague, O., and Deibert, O. The value of the cultural method in the dia-
gnosis of chancroid. J. Urol., 1920, 4, 543-9.

C. F. M.

^SURGICAL TREATMENT OF CHRONIC INTESTINAL

STASIS

When surgical treatment is advocated for cases of constipation which
have not been relieved by medical treatment it is objected that indications
for the operation have not been clearly stated, that the results of operations
have not been fully disclosed, and that there is a tendency to practice one
and the same operation for a number of probably quite different cases.

For an advance on these questions the first thing to do is to sharply
distinguish the cases of constipation which are caused by some form of
mechanical obstruction. Such causes are multifarious, their number is
being continually increased, and the particular form of operative treatment
depends upon the special variety. Much more experience is needed before
it can be stated that some one procedure is the best to be applied to any
number of cases of obstruction.

The surgical treatment of intestinal stasis when there is no naked-eye
mechanical cause of obstruction has its chief advocate in Arbuthnot Lane.

The fourth edition of his work The Operative Treatment of Chronic
Intestinal Stasis, appeared in 1918, and was reviewed in the British
Jourmil of Surgery. The concluding paragraph of that review is as
follows : ' The opinions ofiered by Sir Arbuthnot Lane in support of his
views lack adequate corroboration from his own work, or from that of any
of the contributors to this volume. Where we look for reasoned argument
we find wild assertion ; we seek in vain for any record of mortality, or for
any series of cases in which the previous history, the operative disclosures,
the risk of operation, and the late conditions are set forth in a manner
which allows a reader to form his own judgement. Our faith is tried to
the breaking point.'

Hurst has dealt very fully with the subject of Consti'pation and its

IV. i^

222 REVIEWS

Treatment. He commenced a chapter on ' Operative Treatment ' as follows :
' When constipation is the result of definite organic obstruction of the
intestine, surgical treatment is clearly indicated. But various operations
have been recommended in the last ten years for the relief of constipation
in the absence of this clear indication,' and he proceeds to refer unfavourably
to the various measures.

Since the above, Lane has published remarks on intestinal stasis in
which he has added to the list of causes and indications a great number
of the most various conditions which, in his opinion, combine to make the
colon the essential cause of intestinal stasis. His remedy is the excision
of the gut from near the end of the ileum to the end of the pelvic colon or
siofmoid flexure, and the end to end union between the ileum and the
junction of the colon with the rectum. But these further communications
do not supply what the above-mentioned review desired — information as to
results.

Wide publicity was gained by Metchnikoff for such statements as ' It
is not more rash to say that not only the caecal appendix with the caecum,
but indeed the entire human large intestine is for our organism a super-
fluous organ, the suppression of which would have very happy results.
From the point of view of the digestive function, this part of the intestinal
tube certainly plays no, however small, important role.' If the chapter
from which the above quotation is taken be re-read one can but form the
opinion that Metchnikoff" had reached his conclusion because the functions
of the large intestine were unknown to him.

There is an important cliapter in Lane's book contributed by Keith
under the title ' The Great Bowel ; from an Anatomist's Point of View '.

Keith noted the division between juice digestion in the small intestines,
and the bacterial digestion in the large bowel, which is regulated by, and
regurgitation prevented through, the mechanism of the ileo-caecal valve.
The colon may become an injurious structure, but for the comparative
anatomist the idea that nature has elaborated a great and persistent
structure, such as the colon, for no definite and useful purpose is pre-
posterous.

There is something to be said for tlie proposition that the colon remains
more suited to digest the vegetarian diet of primitive man, and has not
become sufficiently adapted to the concentrated food of modern town-
dwellers. But a diet of coarse vegetables notoriously produces an excess of
flatus which demands expulsion whether upward or downward.

The concentrated diet forced upon healthy young men under the
exigencies of military service has set up much troublesome constipation.
The service rations and the food substitutes in Germany have produced
a marked increase of obstinate constipation, and this was the reason for a
long address by Payr at the 44th Congress of the German Surgical Society
in April 1920.

The most difficult cases are those on the border-line between obstinate
constipation and chronic intestinal obstruction, and the indications for
operation, apart from those deduced from the signs of intestinal obstruction,
are difficult to define. Payr enumerated a great number of the causes of
intestinal obstruction, many of which are only revealed on exploration,
but in attempting to classify them the same mechanical cause of intestinal
obstruction appears in more than one list. After all, Paj^r ended by simply
enumerating types of operations — the separation of adhesions and the

SURGICAL TREATMENT OF CHRONIC INTESTINAL STASIS 223

removal of compression ; the fixation of mobile organs ; tlie reduction by-
suture of dilated viscera ; anastomoses ; intestinal exclusions : intestinal
excisions ; artificial fistulac, temporary or pe)-manent ; plastic operation on
the al)dominal wall and floor of the pelvis : rectal and anal operations.
For obstinate constipation, apart from definite signs of obstruction, the only
procedure he emphasized was that of forcible dilatation of the anus.

J. W. Smith described in 1913 operations for atony and prolapse of
the large intestine, and after 7 years reported the later results, altogether, of
32 cases, 2 of which were fatal. He had communicated with the 30 survivors
and received reports from 26. In 5 cases of dilatation of the caecum,
after plication and fixation of the caecum, 4 had proved complete successes.
One continued well and had worked at munitions for four years; then
there was recurrence of symptoms and he performed hemicolectomy, which
after six months continued a success. Hemicolectomy was performed in
12 cases : 1 died on the sixth day from leakage at the sutures, 3 continued
in good health, and 8 had improved ; 3 of these had to be careful as to diet
to avoid gastric disturbance, 1 complicated by chest disease had only
slightly improved. The later operations, in which end to end was substituted
for lateral anastomosis, showed better results ; 7 cases were submitted to total
colectomy: 4 had completely recovered, 2 were much better and 1 no
better.

A female, aged 28, had suffered for 8 years from constipation com-
plicated by vomiting. For two years she had become so weak as to be
unable to stand or walk. The stomach was dilated, being dragged down
by a distended and prolapsed colon ; the appendix was bound down and
had a V-shaped kink. The ileum, six inches from its termination, was
united to the pelvic colon by lateral anastomosis and all the intervening
bowel excised. The patient replied, ' I am pleased to say the operation you
performed has been very successful. I keep well in health, not exactly
robust, but have been working as a glove machinist for the last three years.'

A female, aged 42, had suffered for twenty years following the birth of
her one child. Severe constipation was accompanied by frequent vomiting,
uterine prolapse, and haemorrhoids. During two previous years she under-
went four operations, the removal of piles, bilateral oophorectomy, ventri-
fixation of the uterus, and fixation of the left kidney. Pain and constipation
were even worse afterwards. She had been confined to bed, had attempted
her life, and was weak, worn, and depressed. Lateral anastomosis between
the ileum and the pelvic colon just above the rectum, followed by excision
of the colon, was performed, and she left hospital 23 days later. The
operation was done in 1912, and seven years later she attended a clinical
meeting. She said she was then better than ever before in her life, she
could eat anything and had not taken a laxative since the colectomy. She
had started work in a cotton mill six months after, and had recently
divided her day between cleaning offices and her own housework.

Taylor's account of 8 cases exhibits the influence of Metchnikoff and
Lane's prejudice against the colon by adopting for various cases of chronic
obstruction one and the same operation, viz. the excision of the large bowel
including the caecum and pelvic colon, followed by an end to end union of
the ileum to the commencement of the rectum.

Case I. Had prolapse of the ascending, transverse, and descending
colon. Two years after the operation he reported that he was employed by
a shipping company, and said, ' I believe the operation to be a great

R 2

224 REVIEWS

success. I am in good general health. I get no pain after eating as before
the operation.'

Case II. Had the termination of the ileum dilated to the size of
a normal stomach with the lumen of the caecum and first part of the
ascending colon narrowed by being thrown into folds as the result of colitis
polyposa. Ten weeks after the operation he was able to play football ; six
months after his bowels moved three times a day.

Case III. Had suffered from constipation, which was not improved
by removal of the appendix. Four years later he began to suffer from
ulcerative colitis, passing blood and mucus, which increased in the following
two years until he had become very thin and weak, with 12 motions a day.
Under caecostomy and irrigation he improved, but the caecostomy opening
being allowed to close, he relapsed. After the operation he became fit for
light work and continued to improve during six months after his discharge
from the hospital.

Cat^e I V. Had a carcinoma in the centre of the pelvic colon, which
caused acute intestinal obstruction, and perforation of the caecum. Tem-
porary relief was given by putting a Paul's tube into the caecum and
draining the abdominal cavity. Three weeks later the excision and end to
end union was carried out. The general health continued good for 18 months,
when metastatic growth in the liver and base of tlie skull appeared.

Case V. Was a similar one up to the recovery from the excision ; there
was no further report.

Case VI. With a faecal fistula following a gunshot wound of the
transverse colon, recovered after excision of the whole colon, but there was
no report as to his motions subsequentl3^

Case VII. Had been an invalid for years, just able to walk quietly
about in her garden, as the result of indigestion. She was seized with
acute intestinal obstruction caused by volvulus of a mobile caecum. The
caecum, which had become gangrenous, with the ascending colon was
excised and an end to end union made between the ileum and transverse
colon. The patient recovered, but did not improve in health or increase in
weight.

Case VIII. After suffering from constipation for many years, had
the appendix removed, when it was discovered that the colon was badly
prolapsed. Some months later, as no improvement had followed, the
caecum and ascending colon were excised, and the ileum joined to the
transverse colon. She was comfortable for 18 months, after which constipa-
tion recommenced, set up by adhesions producing a kink in the small
intestines. The adhesions were freed and ileo-sigmoidostomy performed.
This made the patient worse, owing to collection in the loop intervening
between the anastomosis. Finally, Lane removed the remainder of the
colon and joined the ileum to the upper end of the rectum. From this the
patient was at the time of the report recovering well.

Whilst the last case is the one most definitely in favour of complete
colectomy, in none of the series is there any account of the number of
motions per day consequent upon the direct communication set up between
the ileum and rectum.

In the opinion of Lane and his followers no less an operation than
complete colectomy is satisfactory. Against this may be set 19 cases
reported by Brewster, in which the ileum was anastomosed with the
transverse colon, and only the end of the ileum, the caecum, ascending

SURGICAL TREATMENT OF CHRONIC INTESTINAL STASIS 225

colon, and the beirinninp; of the transverse colon excised. Brewster's cases
included a number ef epileptics suffcrino- from obstinate constipation. The
operation relieved the constipation and improved the general health without
materially influencing the epilepsy.

Case I. An epileptic, aged 11, had a largely dilated caecum, chronic
appendicitis, and adhesion about the hepatic flexure. He recovered
vi'ell, was relieved of the constipation ; the epilepsy returned after two
months.

Case II. A woman, aged 40, had had appendicectomy 12 years before.
A dilated mobile caecum was found. One year after the operation she was
entirely free from the previous constipation and pain.

Case III. An epileptic, aged 22, under X-ray examination presented
stasis at the hepatic and splenic flexures. Following the right colectomy
there was a marked improvement in the general condition, owing to
freedom from constipation, and there was some diminution in the epileptic
seizures.

Case IV. Had had, two years before, a lateral ileo-sigmoidostomy,
which was foUow^ed by persistent nausea, frequent vomiting, and the fiiUing
of a dilated and mobile caecum with faeces. After the right colectomy,
together with excision of the anastomosis and a closure of the opening in
the sigmoid, she was entirely relieved, in three months she gained 15 lb,
in weight, and seven months after underwent a normal labour.

Case V. A woman, aged 52, had had a lateral ileo-sigmoidostomy five
years before, after which she suffered from faecal distension of the ileum
and caecum, below the anastomosis with the sigmoid. After the same opera-
tion as Case IV the patient somewhat improved, but continued to suffer
from a degree of constipation.

Case VI. Suffered from intestinal stasis, or rather chronic obstruction,
caused by a dilated and mobile caecum with adhesions in the region of the
hepatic flexure. Entire relief followed the operation.

Case VII. An epileptic girl, aged 18, with chronic constipation, was
not improved by right colectomy.

Case VIII. A boy, aged 3|, had had appendicectomy for intestinal
stasis a year before. Three months after the right colectomy the mother
reported that the child was normal.

Case IX. An epileptic, aged 25, operated upon for constipation, after
right colectomy resumed work, and during the subsequent three months
there was no return of the epilepsy.

Case X. An epileptic, aged 8, had the caecum dilated and mobile, the
appendix inflamed, and adhesions extending over the ascending and
commencement of the transverse colon. After right colectomy the intestinal
stasis disappeared and the general condition improved, but the epilepsy
continued.

Case XI. A woman aged 30, poorly nourished and extremely con-
stipated, had had for a year occasional attacks of nausea and vomiting.
There was a large and mobile caecum, adhesions about the hepatic flexure,
and scybala in the colon. Six months after the right colectomy she reported
that the constipation had been entirely relieved.

Case XII. An epileptic, aged 35, had been always constipated owing
to a dilated caecum and ascending colon due to adhesions. Ten months after
the right colectomy it was reported that the constipation was entirely cured,
the general condition had improved, the epilepsy persisted.

226 REVIEWS

Case XIII. A man, aged 23, for 5 years an epileptic, had the epileptic
attacks associated with indigestion and constipation. The right colectomy
entirely removed the constipation and tlie general condition markedly
improved but the epilepsy continued.

Case XIV. An epileptic, aged 21, with a large and mobile caecum,
a chronically inflamed appendix, enlarged mesenteric glands, and adhesions
about the hepatic flexure, was influenced by the operation in the same way
as the preceding case.

Case XV. An epileptic girl, aged 12, with constipation and pain in the
right lumbar region, had a large mobile caecum, a long mesentery, chronic
appendicitis, vascular adhesions, and enlarged mesenteric glands. The
constipation was markedly relieved, the epilepsy continued.

Case X VI. An epileptic woman with constipation had a large distended
caecum, chronic appendicitis, and adhesions about the hepatic flexure. She
recovered from the operation but was lost sight of.

Case XVII. A woman had severe constipation for 20 years with
recurring pain in the upper abdomen and was poorly nourished. The
condition found was much tlie same as in the preceding case. She reported
a year after the right colectomy that she felt cured.

Case XVIII. An epileptic aged 20, with constipation had a dilated
end of the ileum, a mobile caecum and ascending colon. Along with relief
to the constipation and general improvement, the epilep.sy continued but
the attacks were milder.

Case XIX. A woman aged 22, who had been an epileptic for a year,
had marked constipation with dull pain in the right lumbar region which
was worse after the epileptic attacks. There was a mobile caecum, chronic
appendicitis, and adhesions over the ascending colon. Right colectomy
removed entirely the constipation and the general condition improved but
the epilepsy continued.

The most noteworthy feature of Brewster's cases was the absence of
any deaths in spite of the many cases of epileptics in bad condition. In
nearl}^ all the constipation was quite relieved and the general condition
improved. There was no definite improvement as regards the epilepsy even
where the attacks seemed to be closely associated with the constipation.
But the patients were able to bear the attacks better and in a few the
operation coincided with a temporar}^ relief. Thus Brewster's results are
opposed to Lane's contention as to the necessity for total colectomy.

Schoemaker, in 68 cases, found the cause to be pericolitis membranacea.
The general symptoms had been pain on the right side of the abdomen with
tenderness from the region of McBurney's point upward towards the
margin of the ribs and across towards the middle line, together with a soft
tumour-like resistance, and signs under X-rays of stasis in the ascending-
colon. The caecum, ascending colon, and to a variable extent the first part
of the transverse colon were found covered by a veil of fibrous tissue. Some
consider this membrane congenital and the stasis secondary, others hold
that the pericolitis is secondary to the constipation, infective organisms or
their toxins spreading through the intestinal wall to set up local peritonitis.
In the 68 cases he excised the caecum, ascending colon, and part, about
12 cm., of the transverse colon, joining the ileum and transverse colon end
to end. Two patients died, one of embolism and the other with signs of
prolonged shock, in whom a post-mortem examination was refused. Fifty
of the patients were followed up; 32 were quite free from abdominal

SURGICAL TREATMENT OF CHRONIC INTESTINAL STASIS 227

disturbance, 8 liad improved but still had some pain, 10 were not benefited —
they still suffered from constipation and pain on the right side.

The examination of the intestine excised showed no sign of colitis ;
there were no changes in the mucous membrane, muscular or serous coats.
The fibrous membrane could be readily raised from the serous coat and
consisted of a cellular connective tissue with numerous thin-walled blood-
vessels, but with no signs of leucocytes or organisms. The membrane,
therefore, appeared to be congenital in origin. In the course of develop-
ment, the caecum as it descends from the hepatic region tends to become
free, whilst the ascending colon with the proximal part of the colon is fused
witii a layer of parietal peritoneum. In the cases cited the caecum was not
dilated or specially mobile, so as to drag on the ascending colon. Indeed,
in some, the caecum was quite high up, covered, along with the commence-
ment of the transverse colon, by a markedly vascular membrane.

Short of excision a mobile caecum and ascending colon may be plicated
in a simple fashion after appendicectomy by suturing together the anterior
and external taeniae as far up the ascending colon as seems desirable.
Ten Horn, of Ghent, has reported recently as to the favourable results. It
is merely a prolongation of the suture burying in the stump of the appendix.
Waugh, in 180 cases, adopted a more extensive operation, requiring a much
freer abdominal incision, and with the result of rendering the caecum and
ascending colon more fixed than is natural. Waugh incised the parietal
peritoneum to the outer side of the caecum and ascending colon from the
brim of the pelvis to the level of the duodenum. After raising the outer
edge of this peritoneal incision as a flap, he cleared out fat from the front of
the lumbar muscles, laid the caecum and ascending colon in the hollow
so made, and sutured the peritoneal flap over the outer side to the anterior
taenia.

The increase of coarse vegetable food in the diet has apparently caused
a notable increase of cases of volvulus of the sigmoid flexure. This has been
noted by Neugebauer in Russia, by Neudorfer in Germany, by Guimbellot
and Okinczye in France, If the case is seen whilst there is only pain and con-
stipation, and the sigmoid flexure is merely mobile, excision and end to end
union should be carried out without delay. If, unfortunately, volvulus has
occurred and set up acute intestinal obstruction, then incision, with end to end
union, together with a temporary caecostomy, is best ; failing that, the excision
of the volvulus, after tying in a Paul's tube above and below, followed later
by closure, which, however, is difiicult to accomplish. The proposal attri-
buted by Neudorfer to Pachhammer in 1912, viz. to make an anastomosis
between the proximal and distal arm of the volvulus, is likely to fail. After
temporary relief a further twist of the volvulus may involve the anastomosis
and set up recurrence of the obstruction. An incision of the volvulus
is open to the danger that the orifice may be situated below the upper end
of the obstruction.

One of Okinczye's cases is instructive. In 1915 a man of 47 had
an attack of intestinal obstruction which passed off spontaneously. In
June 1916 a more prolonged attack was treated on the 12tli day by caecos-
tomy, but as this did not relieve him, ten days later the sigmoid flexure was
opened. From this faeces escaped regularly, but from the lower end, and a
prolapse of 20 cm. of the sigmoid supervened. An X-ray examination then
showed a volvulus of the sigmoid with the caecum and ascendino- colon
much dilated. At last, in November 1920, the volvulus was excised and an

228 REVIEWS

end to end suture closed the opening, which was followed by an uncom-
plicated recovery. Against the foregoing may be set the case recorded by
Guimbellot. A woman aged 26 had been constipated since childhood, four
to five days intervening between her stools, attended with pain, especially in
the left hypochondrium. Acute intestinal obstruction supervened, and 36
hours after the onset a volvulus of the sigmoid was exposed, the loop being
distended to the size of a man's thigh. The volvulus was excised and the
two ends united. There was a spontaneous motion on the sixth day. She
was discharged after a month. Four months later she was well, but with
some constipation and colicky pains, an X-ray examination discovering
a delayed passage through the colon.

Conclusions. When a case of chronic intestinal stasis presents difficulties
in diagnosis, the recommendation of Greig Smith may be adapted. He
advised that a surgeon, when in doubt as to whether a patient was suffering
from acute intestinal obstruction calling for operation, should sit down by
the bedside and observe the patient for an hour or more.

After a purge has been administered the progress of its effect along the
intestinal canal may be followed. Variations in the movements and disten-
sion of the bowels, changes as regards cutaneous hyperaesthesia, muscular
rigidity, reflexes, and deep tenderness may be noted and then compared with
the patient's sensations. Similar observations may be made after the patient
has swallowed some gruel containing bismuth or barium sulphate, the course
of the intestinal contents may be observed through the X-ray screen, and
photographs may be taken at other junctures than those fixed beforehand.

Hitherto the examination of the wall of the colon removed for chronic
constipation has often been barren of results. In a case of a caecum and
ascending colon removed by Spencer, Keith found in the submucous tissue
a remarkable collection of large branched cells loaded with pigment, melanin
chromatophores. It is possible that in the future further evidence may be
forthcoming as to pathological fine alterations in the neuro-muscular
mechanism of the large intestine. Whether partial or total colectomy
be done, it is not clear why it has been usual to sacrifice the ileo-caecal
valve. The preservation of the valve might well have two advantages, the
prevention of the ascent of bacteria so as to disturb the juice digestion in
the ileum, and the prevention of too frequent motions.

Bbswsteb, G. W. W. Right colectomy. Report of 19 cases. Tr. Am. Surg.
Ass., 1918, 36, 461.

Bbitish Journai. or Subgeby. Review of Lane's "Operative treatment of
chronic intestinal stasis". 4th ed. Brit. J. Surg., 1919 6, 609.

GuiMBEiiiiOT. Volvulus de rS iliaque traite avec succes en periode d'occlusion
aigue par la resection de I'anse volvuleeavec suture intestinale immediate. Bull,
et mem. Soc. de chir. de Par., 1920, 46, 1456.

Neudobfeb, a. Zur Behandlung des Volvulus der Flexura sigmoidea.
ZentraM.f. Chir., 1920, 47, 1457.

HuBST, A. r. Constipation and allied intestinal disorders. 2nd ed. 1919,
393.

Keith, A. The great bowel ; from an anatomist's point of view. Lane,
W. A., The Operative Treatment of Chronic Intestinal Stasis. 4th ed. 1918, ch. vii,
202.

SURGICAL TREATMENT OF CHRONIC INTESTINAL STASIS 229

ImAtste, W. a. ( 1). Cancer of the colon, its causation and treatment. Lancet,

1920, ii, 1184.

ImATUB, W. a. (2). Disease and chyme infection. Lancet, 1919, i, 767.

Lane, W. a. (3). Chronic intestinal stasis. What are the indications for
operative treatment. Lancet, 1919, i, 333.

Lane, W. A. (4). The operative treatment of chronic intestinal stasis. 4th ed.
1918.

Metchnikoff, is. Etudes sur la nature humaine. 1903, ch. iv, 87.

Neuoebauer. Spastische Obstipation und Volvulus, Med. Klin., 1919, 15,
265.

Okinczye, J. Sur le volvulus de I'S iliaque. Bull, et mem. Soe. tie chir. cle Par.,

1921, 47, 29.

Payb, E. Obstipationsursachen und -formen. Konstitutionspathologie und
Eingeweidesenkung. Uber die Anzeigestellung zu Operationen bei Obstipation.
Arch./, klin. Chir., 1920, 114, 894.

ScHOEMAKER, J. Pericolitis merabranacea. Arch. f. Min. Chir., 1920, 114,
859.

Smith, J. W. Atony and prolapse of the large intestine. Brit. M. J., 1920,
i, 243.

Spencer, W. G., and Keith, A. Intestinal stasis followed by cystic dilata-
tion of the caecum without intestinal obstruction. Brit. J. Surg., 1921, 8, 452.

TayIiOR, J. Colectomy. Lancet, 1919, ii, 197, 457, 547.

Ten Horn. Die Plikation des Caecum als Behandlung der Obstipation.
ZentraWl. f. Chir., 1919, 46, 354.

Waugh, G. E. The morbid consequences of a mobile caecum and ascending
colon, with a record of 180 operations. Brit. J. Surg., 1920, 7, 343.

W. G. S.

MELANIN, MELANOMA, MELANOTIC CANCER

Recent observations have increased knowledge regarding the pigment
melanin, a substance which has presented special difficulties under chemical
examination. These observations have an important bearing upon questions
relating to pigmented benign formations, melanomas, as well as to the
malignant melanoblastomas or melanotic cancer.

The following may be noted as some of the steps by which advances
have been made.

In 1887 Thormahlen originated the idea of a colourless melanogen by
finding that the urine of a woman suffering from secondary melanotic
cancer, when treated with sodium nitroprusside and caustic potash, turned
blue-green. There were, however, substances in the normal urine of cattle
and horses which gave the same reaction. Herzog and Zeller examining
urine from a similar case at a more advanced stage, when the urine

230 REVIEWS

had become brown from melanin, distinguished the reaction of melanin ;
the solution turned green with the Thormahlen test, and black with per-
chloride of iron, whereas previously colourless melanogen turned with the
Thormahlen test a steel blue or Berlin blue.

In 1896 Bertrand, examining the juice of plants which are the source
of black Japanese lacquer, found that a kind of melanin was produced by-
oxidation through the aid of an enzyme. This enzyme being isolated acted on
tyrosin, turning it first a violet-red, then causing a black deposit of melanin.
The enzyme, being considered an accelerator of the oxidation of tyrosin, was
named tyrosinase.

Attention was also directed to the blood of those insects which turns
black on exposure to light. Hollande demonstrated the presence of a tyro-
sinase in the blood of such insects ; it was also found in the ink-sac of Sepia.
In contact with air this tyrosinase accelerated the oxidation of a chromagenic
material, melanogen, to form melanin.

In 1 909 Meirowsky found that pieces of skin taken post mortem from
brunettes, also frozen sections of the same, were darkened by exposure to
a quartz lamp or by heating up to 56° C. Microscopical examination of a
section showed that the darkening was produced by a heaping up of pig-
ment in the basal cells of the epidermis. Portions of skin taken post
mortem from a case of Addison's disease and kept in an incubator for 5 days
underwent a still greater degree of darkenino-. In 1910 KoniiJ-stein, in
order to dispose ot the objection that the above was a post-mortem effect,
excised both adrenals from dogs. In animals which survived a pigmen-
tation of skin occurred, similar to that taking place in Addison's disease.
The darkened patches of skin, removed intra vitam., and placed in an incu-
bator for 48 hours at 50° C. were made much darker, and if the sections
were boiled in water for 5-7 minutes before being placed in the chamber,
they became darker still.

In 1914 Bittorf demonstrated that the frozen sections of skin from
Addison's disease were similarly darkened by dilute solutions of tyrosin and
of^ adrenalin, the latter being the more active. In a solution of adrenalin,
1 in 1,000, the sections were rendered quite black in 4-5 hours ; in a solution,
1 in 100,000, in 21 hours the sections had become distinctly darkened. In
the case^ of a soldier who had been shot through the loin, and in whom it
was conjectured that the adrenals might have been injured, Leschcziner
found that exposure to a quartz lamp caused the skin so exposed to darken
in a way which persisted after 7 months. Pieces of tliis skin, cut out into-a
vitam from the man, darkened in the tyrosin and adrenalin solutions, like
the skin from Addison's disease.

Bloch discovered that 3, 4-dioxyphenylalanin — for short ' dopa ' — in an
aqueous solution, 1 in 1,000, could be used as a test for the presence of
tyrosinase in the protoplasm of the cells of the malpighian layer of the
epidermis, by which pigment granules of melanin were formed.

Melanin. Melanin is a pigment which, almost absent from the skin of
a blonde not exposed to the Hght, is the marked characteristic of the
stratum germinativum of the epidermis of the negro. The total quantity
of melanin under normal conditions in the skin of a negro has been estimated
at not more than 1 grm. In a fresh melanotic cancer the melanin may
amount to 7-10 per cent, by weight of the whole ; the total quantity of
melanin produced in cases of generalized melanotic cancer may reach from
300-500 grm. The ink of a squid consists of melanin ; as the animal con-

MELANIN, MELANOMA, MELANOTIC CANCER 231

tiuues to dischar<^e it under repeated irritation the colour is weakened until
finall}^ a colourless fluid is discharoed from the sac.

Chemical examination has proved that melanin is an iron-free pigment,
unconnected in origin with haemoglobin. As distinguished also from
haemoglobin, it contains suli)hur ; in the material from a melanotic cancer
as much as 10 per cent, of sul[)hur has been found, in the melanin from
a squid as much as 12 per cent.

The source of melanin is the proteid molecule, and the amino-acids
concerned in its formation are probably the sulphur-containing cystin, the
phenolic tyrosin, and the indol-derivative tryptophane. Dioxyphenyl-
alanin, the so-called ' dopa '. is closely allied to tyrosin, but contains an
additional phenolic hydroxy 1, being a catechol derivative. It is an amino-
acid which has been obtained from plants readily forming black pigment
when injured— e. g. the broad bean. It is very readily blackened by oxida-
tion in the presence of tyrosinases, and can therefore be used as a test for
such enzymes.

According to Bloch, the normal as well as the pathological pigmentation
of the skin is produced by the epithelium of the stratum germinativum, in
deep pigmentation also by the superjacent cells of the stratum spinosum,
also by the deep layer of the cells of the hair follicle and of the hair papilla,
the latter determining the colour of the hair. These are the normally
active pigment-forming cells. Under normal conditions the cells are quiescent
and the pigment formation small. The same applies to the cells of
a stationary melanoma. Under abnormal conditions the cells become active
and there is more active pigment formation. The active pigment formation
then occurs in cells which are undergoing division. Indeed in a rapidly
growing melanotic tumour the division of cells is in advance of the
formation of the pigment, so that some of the secondary growths are not
pigmented.

The formation of the melanin pigment occurs in the protoplasm of
the cell, the nucleus does not take an obvious share in the process. The
dioxyphenylalanin or 'dopa' solution serves as a test for the presence
of tyi-osinase. Bloch explains that there exists in the cells of normallj'-
pigmented skin an enzyme which blackens with 'dopa', and that thi.s
enzyme is absent from the skin of albinos and in the non-pigmented
patches of the skin of an animal elsewhere spotted by pigment. _ Upon
the relative amount of this oxidizing enzyme depends the reaction to
a stimulus such as light. Hence may be explained the variations in the
degree of pigmentation produced by the action of rays of light on the skin
of different individuals. Also it may be supposed that in Addison's disease
there is a failure on the part of the suprarenals to form adrenalin from the
mother substance. As a consequence there is an accumulation of the
latter, which, collecting in the epidermal cells, is there converted by the tyro-
sinase into melanin.

Melanin pigment cells. The study of the distribution of the melanin
pigmented cells of vertebrates and invertebrates shows that it occurs most
commonly in cells derived from embryonic epiderm, and particular!}^
so in man. This includes the skin and appendages, both above and
underneath the shell of a crustacean, and the choroid coat in the eye.
Besides there are found pigmented cells around the abdominal cavity or
coelom, and along the course of blood-vessels and nerves. In all of these
places the areas of pigmentation are not strictly defined, but there are found

232 REVIEWS

outlying cells in addition. Besides the skin and choroid coat of the eye,
there are melanin pigment cells in the olfactory epithelium and in that lining
the labyrinth. Cells may be found which have apparently wandered out
into the sclerotic. The occurrence of a melanotic tumour growing from the
pia mater or choroid plexuses of the brain may be explained as originating
in cells which have been derived from embryonic epiderm, or represent
pigment cells in the sheaths of nerves and arteries in lower animals.
A melanotic tumour of the palate may be connected with the pigmented
patch in the mouth and throat of, e. g. some dogs.

The pigmentation of cells around the primitive coelom may afford an
explanation of the pigment cells of the suprarenals, melanotic patches may
be seen on the surface of the gland ; in some birds and animals pigment
cells have been noted in the tunica albuginea of the testes. In domestic
animals melanotic growths arise in the retroperitoneal tissue ; a melanotic
growth of the ovary is more often secondary, yet the above gives a possible
explanation of a primary melanoma of the ovary. In one case it originated
in an ovarian dermoid cyst. In the thorax, of sheep in particular, the
endocardium and the endothelium of the large vessels are spotted with
pigment, from which it is likely that a primary melanotic tumour may
arise.

In the embryo the source of the melanin pigment is not in the ovum.
The frog's ovum is pigmented but not so the ova of tritons and salamanders,
in which the melanin pigment appears after the formation of blood. The
development of the melanin pigment cells can be watched in the transparent
leptocephalidae ; also the choroidal pigment in the development of the eye
of vertebrates ; it originates from non-pigmented cells.

The chromatophores. Melanin pigment is contained in large cells
with multiple branches lying amongst epithelial cells, also beneath the
epithelium in the cutis and elsewhere. Chromatophores are seen in inverte-
brates along the blood-vessels, having amoeboid properties, in Am^jhioxus
along the course of the nervous system, in crustaceans around the intestines.
In melanotic cancer the pigmented cells may be spindle-shaped or rounded.
Such chromatophore cells contain much more pigment than any individual
epithelial cell.

A precisely opposite explanation to the view that the epithelial cell
of the stratum germinativum forms the pigment is that the pigment is
formed in these chromatophore cells, which are mesoblastic in origin.

Those that believe that these cells are merely chromatophores, pigment
carriers, which take up the pigment from the epithelial cells or melanoblasts,
to carry it away along the lymphatics to the lymphatic glands, note that
chromatophores are absent under patches of vitiligo and nonpigmented scars.
But at any rate, when melanotic cancer is developing and the cells are
rapidly dividing, these mobile chromatophores become capaljle of forming
pigment in distant metastatic growths.

That cells of mesoblastic origin in insects can form melanin in their
protoplasm was stated by Hollande in the case of insects, the blood of which
blackens on exposure to the air. The vacuoles of the phagocytes, into
which particles like bacteria or inorganic granules are taken, contain plasma
and the tyrosinase. Under the influence of light, owing to the presence of
a chromagenic melanogen and a tyrosinase enzyme, granules of melanin are
formed in the vacuoles. Subsequently the melanin leaves the phagocyte,
passes away in the blood, and is taken up by other cells.

MELANIN, MELANOMA. MELANOTIC CANCER 233

The structure of melanomas and melanotic cancers. Passing on to
abnormal collections of the melanin pigmented cells, melanotic moles and
patches have two arrangements of cells which, however, may be combined.
In one, characteristic of the pigmented moles of tlie skin, the pigmented
cells are arranged in rows more or less vertical to the surface, somewhat
resembling the cortex of the suprarenals ; or the cells have a somewhat
alveolar arrangement. Outside these cells are scattered chroinatophores.
It is especially in melanotic cancers derived from the skin that tlie alveolar
arrangement persists and is continued in the metastatic growths, particularly
of the lymphatic glands. This suggests an epithelial origin, and that the
malignant growth is a carcinoma. With this accords the tendency to spread
first to the lymphatic glands corresponding to the area.

The other type of melanoma suggests that the chromatophores are the
basis. If the melanomatous spot is in loose tissue, the cells are large with
nmltiple branching processes. In new growths, especially those arising in
the internal organs of animals, the cells resemble those of spindle-celled and
round-celled sarcomas, as if the above mentioned cells had, in the course of
multiplying, become compressed.

Referring to veterinary pathology, there is clear evidence that in cats
and dogs melanotic cancer commences primarily and almost exclusively in
the skin and eye. In horses, especially grey horses which become white,
the common primary growth is from the skin of the region of the anus. In
the majority of reports concerning horses, cattle, and sheep, no attempt is
made to note the situation of the primary growth. A source in a suprarenal
capsule is particularly igniored. Hence there are returns of melanotic cancer
of horses in the muscles, lymphatic glands, heart, lung, spleen, parotid, in
cattle in the stomach, in sheep in the bones. Statistics given by Lubarsch
illustrate the frequency of melanotic cancer in the Berlin Veterinary
Institutions, 175,745 horses, cancer and sarcoma in 527, melanotic cancer
and sarcoma in 226, i. e. 42-88 per cent. In grey and white horses there is
definitely an increasing tendency with age, which is not the case in human
beings. An old explanation of the predisposition in white horses is that
the chromatophores overloaded by the withdrawal of pigment from the hair
and skin fail to be excreted by way of the blood.

Diffused melanotic pigment. Matsunga's observation is important in
relation to the cases of melanotic cancer in which a diffuse pigmentation
occurs. He made a post-mortem examination on a man, aged 41, in whom
a pigmented mole on the forehead had been noted, for four years before its
removal, to be exhibiting signs of growth. It had been removed one year
before death, along with large glands from the neck. At the time of
removal the primary growth had already ulcerated, and beyond the outline
of the tumour, when excised, there appeared a diffuse brownish pigmenta-
tion of the connective tissue. At the examination after death there were
found numerous metastases and in addition a generalized pigmentation of
the skin of a diffused brown colour. Much of the pigment was found in
spindle-shaped and stellate cells, and the ' dopa '-reaction of Bloch was yielded
both by epithelial and connective tissue cells. By this it was shown
that fixed connective tissue cells, as distinct from wandering cells, were
pigmented and yielded a positive reaction. Besides the fixed connective
tissue cells, endothelial cells of blood-vessels, reticulum cells in lymphatic
glands, also epithelial cells of the kidneys, lungs, and thyroid gland, all
gave a positive ' dopa ' reaction.

234 REVIEWS

These observations indicate that a melanin-producing enzyme can be
discharged in solution from the tumour cells, which is carried off by the
blood, and, arriving at non-pigmented mesoblastic cells, is capable of pro-
ducing the pigment. This brings the diffuse pigmentation in the case of
melanotic cancer into line with that of the pigmentation following Addison's
disease. It further points to the starting of the primary malignant
development in a previously quiescent mole as being connected with a pro-
duction to excess of the pigment-forming enzyme. In relation to the origin
of cancer in general, the cause of melanotic cancer is intimately bound up
with the melanin pigment.

The pigmented mole on the skin. There is at any rate one established
fact — that to prevent melanotic cancer from arising in man, au}^ pigmented
mole or patch which shows the slightest tendency to change should be cut
out. Moreover, a surgeon, when called upon to make an incision under an
anaesthetic, should take the opportunity of removing a mole existing on the
neighbouring skin.

The danger following upon tlie irritation of a pigmented spot on the
finger or beside the nail, the melanotic whitlow of Hutchinson, is well known.
Yet owing to the ubiquity of these moles the possibility of comj)]ication may
be overlooked.

A small boy, a brunette, both the mother and father being South
European brunettes, had, as well as his parents, many moles, including
three on the toes of one foot. One of the black spots on a toe had become
inflamed and commenced to ulcerate. It had been seen by several medical
practitioners, who had all diagnosed the condition to be the result of frost-
foite, in spite of the ulcer being at the base of the toe, the circulation of the
feet good, and the child well cared for. When cut out the ulcer was found
to be a commencing melanotic cancer, the other two patches quiescent
melanomas ; the glands in the groin showed small-celled proliferation with
some large cells containing melanin pigment.

Even more dangerous are the moles about the genitals and anus.

Holland, in 1908, collected 52 recorded cases of melanotic cancer of the
vulva and the vaginal orifice. The cases had nearly all been treated too
late, only one being known to be free from recurrence three years subsequent
to the removal. The records were defective on important points, viz. the
origin in a pigmented mole and the early infection of the lymphatic glands.
A further difliculty was that some were probably metastatic in origin.
Doran, in 1905, was the first to distinguish a melanotic growth on the vulva,
secondary to a melanotic cancer of an adrenal, and he subsequently mentioned
three other similar cases.

Miescher examined enlarged crural lymphatic glands which had become
affected from a pigmented mole on the thigh after it had turned malignant.
The glands exhibited the alveolar t3^pe of melanotic cancer and some of the
tumour cells gave the ' dopa ' reaction, others did not. The cells which
gave the positive reaction were cells which could be seen to already contain
some pigment and were of epidermal origin.

Melanoma and melanotic cancer of the eye. Apart from the regular
pigmentation, melanomatous spots are seen in the choroid and in its
neighbourhood. Such patches are very common on the iris of horses.
They also occur in non-pigmented tissue such as the conjunctiva.

The choroid pigment in the embryo appears to develop in previously
colourless cells derived from the epiderm, and melanotic cancer, when it

MELANIN, MELANOMA, ]\IELANOTIC CANCER 235

arises, starts in these pigmented cells. But histologically both the primary
growth and the metastases have the general structure of spindle- and
round-celled sarcoma rather than of alveolar cancer. As differing from the
pigmented basal cells of the epidermis, the cells of the choroid fail to yield
the 'dopa' reaction. Bloch's explanation of this is that the choroid cells
are entirely quiescent, no pigment metabolism going on in them under
ordinary circumstances.

Moore has carefully described the quiescent melanomatous patches of
the choroid as seen by means of the ophthalmoscope, and in one case he had
the opportunity of examining the eye, after death from a totally uncon-
nected cause. The melanomas were in four cases discovered during routine
examination, and consisted of deeply pigmented patches of the choroid in
the neighbourhood of the optic disk, with normal retinal vessels in front.
In the eye examined after death there was found no essential difierence in
histological structure from melanomas elsewhere. In the same eye, in the
ciliary muscle, was a group of melanin chromatophores such as is met with
in the eyes of negroes.

The foregoing cases had presented no disturliance of vision, but Moore
quoted previous descriptions of appearances of such patches suggestive of
a commencement of malignant changes. A remarkable feature of melanotic
cancer of the eyeball is the delay in the appearance of metastases, and that
not in corresponding lymphatic glands, but especially in the liver, followed
by melanuria. A delay of ten years or so has been many times reported,
and Moore quoted a case which survived to die of abdominal metastasis
17 years after the removal of an eyeball for melanotic cancer. Were it not
for the similarity in the appearance and course, a separate new melanotic
growth in the abdomen might seem a more likely supposition, rather than
a metastasis so long after the primary disease.

Andbewes, C. H. On a case of malignant melanoma of the vulva. St. Earth.
Hosp. J., 1921, 28, 57.

B1.0CH, Bb., u. LoffIiEB, W. Untersuchungen fiber die Bronzefiirbung der
Haut bei der Addison'schen Krankheit. Deutsches Arch. f. Jclin. Mccl., 1916-17,
121, 262.

Bbahk, B., u. SCHMIDTMAWN, M. Pigmentstudien. Zur Kenntniss des
Melaniiis und des braunen Abnutzungspigments. Arch. f. path. Anat. (&c.),
1919, 227, 137.

DOBAN, A. Malignant melanotic vulvar growth secondary to an adrenal tumour

of the kidney. J. Obst. c$- Gynaec. Brit. Emp., 1905, 11, 447, and 1908, 14,

414.

Hackenbebg, E. Ueber einen Fall von Melanosarkom des Rektums. Zen-

tralU. f. Chir., 1920, 47, 578.

Eebzog, p., u. ZEI.1.EB, H. Uromelanin und Uromelanogen. Biochem.

Ztschr., 1919, 96, 233.

H01.1.AND, E. Malignant melanoma of the vulva. /. Ohst. 4' Gf/naec. Brit

Emp., 1908, 14, 309.

HOLLAWDE, A. Ch. La formation du pigment brim-noir (melanine) du cours de
la phagocytose chez les insectes. Compt. rend. Soc. de hioL, 1920, 83, 726.

Eben, O. Melanose. Wien. med. Wchnschr., 1919. 69, 947.

236 REVIEWS

LuBABSCH, O. Zur vergleichenden Pathologie der melanotischen Gewachse.
3Ied. Klin., 1920, 16, 195.

Matsunaga, T. Ueber diffuse Pigmentierung mit Melanin bei allgemeiner
Melanosarkomatose. FranJcfurt. Ztschr. f. Path., 1919. 22, 69.

MiESCHEB, G. Ein Beitrag zur epithelialen Genese der malignen Melanome
der Haut. Centralb. f. allg. Fath. u. path. Anat., 1919, 30, 353.

Moore, R. F. (1). Melanoma of the choroid. Roy. Loncl. Ophth. Hosp. Rep..
1914, 19, 411.

Moore, R. F. (2). Proc. Roy.Soc.of3Ied. Lond., 1918-19, 12, Ophth. Sect., 60.

Novae, I. Kritischer Beitrag zum primjiren Melanosarkom des Ovariums.
Arch./, aynaek., 1920, 112, 183.

SaIiEOWSEI, E. Ueber die Darstellung und einige Eigenschaften des patho-
logischen Melanins. Arch. f. path. Anat. (&c.), 1919, 227, 121.

ThobmahZiEIT, J. Mittheilung fiber einen noch nieht bekannten Korper im
pathologischen Menschenharn. Arch. /.path. Anat. (&c.), 1887, 108, 317.

W. G. S.

ACUTE SUPPURATION ABOUT THE WRIST TREATED
BY INCISION DIVIDING THE ANNULAR LIGAMENT

Septic infection of the hand being neglected for a week or so, acute
suppuration becomes established in the palm and spreads among the
tendons into the lo^yer third of the forearm, also to the wrist and carpal
joints. The question then is whether the patient's life can be saved, short
of an amputation, by incisions which will arrest the septic inflammation.
The resort to several short incisions and the insertion of drainage tubes,
granted that the process of suppuration becomes arrested, generally renders
the hand useless for all finer movements. A more extensive operation,
imitating the operation for tuberculous disease introduced by Lister, has in
the two cases quoted below, recorded by Helferich and Muraud, enabled
much finer movement to be gained. Patients suffering from tuberculous
disease involving the wrist, carpus, and the lower third of the forearm, after
the Lister operation have been enabled, e. g., to write a remarkably fuie
hand. When treating acute suppuration by making small incisions and
inserting drains, it has been customary to pass tubes from the flexor aspect
of the forearm, under the annular ligament, and out by the palm. The
flexor tendons become firmly glued together and all movement of the
tendons is completely and permanently lost.

Chaput reported that in five cases he had removed the carpal semilunar
and passed a tube through from the flexor to the extensor aspect. One
man was aged 68, two men aged 65, one woman aged 60, and another 55.
Amputation was thus avoided; the hand healed, but all the fingers were
firmly ankylosed ' en grifie '.

V. Saar and Schamberger recall the old names for the lines in the skin
of the palm, the longitudinal midline continued over the wrist-joint, the

ACUTE SUPPURATION ABOUT THE WRIST, ETC. :.'37

so-called liiiea fortunae, the line deviating from it below the wrist to skirt
the thenas eminence, the Unea vitalis, also the two transverse lines, the
distal one, the llaea musalis, and the proximal, the iiiLea cephalica. These
lines form landmarks for the structures in the palm. A lon<atudinal
incision a few millimetres to the ulnar side of the linea fortunae has the
ulnar nerve and artery to one side and the median nerve to the radial side.
If tlie incision begins above the linea cephalica the arteries of the palmar
arch may be avoided, and no tendon is injured when the incision is con-
tinued up through the annular ligament.

Helferich's case. A man aged 32 injured the little finger of his right
hand. Acute swelling of the hand and lower two-thirds of the forearm
followed, and the axillary glands became enlarged to the size of hazel-nuts.
Seven days later, under general anaesthesia, and after applying a tourniquet,
an incision was made to the ulnar side of the middle line longitudinally
through the annular ligament, without injuring the ulnar nerve or artery or
the deep palmar arch. Pus was found among botli the superficial and deep
flexors, also along the interosseous ligament to above the middle of the
forearm. The whole was cleaned with the aid of a 0'6 per cent, salt
solution ; after loosening the tourniquet, bleeding-points were tied, and
then the wound was filled with iodoform gauze. The gauze remained in
situ for ten days. The temperature at the operation was 39-1° C, on the day
after 37-3-39*5° C, and on the second day 37-6-38-8° C, it became normal
on the third day and remained so. Twelve days after the operation, again
under a general anaesthetic, and, after applying a tourniquet, granulations
were scraped away, the margins of the skin undermined, the long incision
sutui'ed. There remained the primary lesion of the little finger where
the flexor tendon had sloughed. The patient was discharged healed after
two months. 3^ months after healing the man was examined : he had
been some time at work, he could flex all his fingers well except the
little finger. The united incision was firm, there was no weakness of the
annular ligament, the state of the muscles of the forearm was equal to
that of those on the left side.

Mnrand's case. Muraud reported that a nurse, aged 52, punctured
her left thumb whilst dressing the stump after an amputation through the
thigh for multiple wounds infected by streptococci. A small whitlow
formed, which was aggravated two days later by the left hand and fore-
arm being accidentally squeezed. Eight days after the puncture acute
suppuration had extended to the palm and above the wrist, also to the
dorsal aspect. Above streaks of inflamed lymphatics stretched upward to
inflamed axillary glands. A long median incision was made, extending
from the palm through the annular ligament to the junction of the lower
and middle third of the forearm. A large quantity of pus escaped from
over and amono; the tendons. Another longitudinal incision on the dorsum
exposed the extensor tendons, also bathed in pus. From both sides holes
led into the wrist-joint and among the carpal bones. All the carpus was
removed except the trapezium and pisiform bones. The pus yielded a pure
growth of streptococci. The after-treatment by the Carrel Dakin method
of irrigation was continued for a fortnight, after which the hand was fixed
in plaster, with the wrist dorsiflexed and movement of the fingers begun.
Four months after the operation the patient could use her thumb and fingers
sufficiently to grasp a book, could dress herself, do her own hair, insert
hairpins and hold a glass to drink with the aflected hand. Six months

IV. s

238 REVIEWS

afterwards the thumb could approach to within 1 cm. of the httle finger
and she could lift a chair with that hand. Fourteen months after the
operation she could sew, iron, and embroider, and do many other things ; the
thing she could not do was to button the opposite glove, owing to general
reduction of the movement of the thumb and fingers.

Lec^ne, in the discussion on Muraud's paper, commended the procedure
which he had adopted since 1912 ; for such cases drainage above and below
the annular ligament led to deplorable results.

Chaput. Drainage translunaire des arthrites aigues suppurees du poignet.
Bull, et mem. Soc. de cliir. de Par., 1914, 40, 109.

Hz:i.FERiCH. Ueber die Behandlung schwerer Phlegmonen. Berl Uin.
WcJmschr., 1892, 29, 61.

MuRAUD, J. De la resection du carpe, combinee a la section du ligament
annulaire, anterieur dans le traitement de I'arthrite suppuree du poignet ; com-
plication d'un phlegmon de la gaine des flechisseurs. Bull, et mem. Soc. de chir.
de Par., 1921, ^7,227.

V. Saab, G. F., u. Schaubebgeb, R. Der ulnare Langsschnitt. eine Schnitt-
flihrung fiir Operationen im Bereiche der Volarfliiche des Handgelenks und der
Hohlhand. Zentralhl. f. Chir., 1913, 40, 993.

W. G. S.

■-■,3'

ABSTRACTS

SURGERY

Cebm-ezzi, a. Contributo alia cura radicale delle grand! ernie ombelicali e degli
sventramenti niediani. [Treatment of large umbilical and ventral hernias.]
Arch, ital di chir., 1920, 2, 352.

Plastic operations for the closure of large apertures in the abdominal
wall by means of flaps cut from the sheaths of the recti muscles were
introduced by Nable (1897), Karewsky (1904), and Polya (1905). The
feature common to the three methods was the formation of a more or
less extensive flap from the anterior layer of the sheath of each muscle with
its base towards the middle line. Nable sutured the two recti muscles in
their whole thickness, disregarding the closure of their sheath ; Polya, who
applied his method to comparatively small hernias only, united the two flaps
by means of a purse-string suture and then drew together the external
margins of the incisions in the sheaths. Karewsky extended the method to
hernias of large size, reflecting the flaps over the aperture, suturing their
margins, and completing the closure by suturing in strata.

The relative ease with which the aponeurosis of the external oblique
muscles can be approximated, and even superimposed, has led to the intro-
duction of further modifications in these methods. In so far as these involve
the isolation of extensive aponeurotic flaps they are regarded by Cernezzi
as of doubtful value, since they tend to weaken the abdominal wall not only
by reducing the vascular supply of the aponeurosis, but also by altering the
functional relations of the abdominal muscles. The operation recommended
Ijy Cernezzi himself is very similar to that of Karewsky, although worked
out independently. Cernezzi noticed that in cases where suture by strata
was impossible with any prospect of satisfactory results, the diflic\ilty
experienced in closing the hernial aperture lay in the posterior layer of the
rectus sheath : this powerfully resisted traction towards the middle line,
while the anterior layers could be readily approximated. The difference in
the behaviour of the two layers is explained by the difference in their origin ;
the deeper layer is, in fact, merely the aponeurosis of the transversalis
muscle reinforced by the deep layer of that of tlie internal oblique, and its
fibres run in the direction of the traction applied ; the superficial layer is
formed from the aponeurosis of the external obHque, and its fibres, owing to
their oblique course, allow of a certain degree of lateral deviation. An
elliptical cutaneous incision is made over the hernial protrusion and the sac
dealt with in the usual way. The sheaths of the recti muscles are next

240 ABSTRACTS

exposed for a long distance above and below the hernial aperture, and cut
longitudinally at about a finger's breadth from their internal edge, the
incisions being curved obliquely inwards at the extremities. The flaps are
reflected towards the middle line and sutured together at their margins. In
this way the hernial aperture is closed and the united edges of the flaps
serve as a good line of support for the subsequent superficial sutures. The
remaining external portions of the sheaths are then brought together and
sutured in the middle line, no difficulty occurring in their approximation for
the reasons before mentioned. The superficial fibres of the muscles are to be
included in the sutures, so that the muscles may be drawn together at the
same time. The point of importance in this technique is that the plastic
operation should extend far beyond the longitudinal diameter of the hernial
aperture, and be proportional to the greater or less degree of diastasis of the
recti muscles.

Since 1907 Cernezzi has operated on 16 cases, 8 umbilical and 8 median
ventral hernias. Of the 8 umbilical hernias 3 were recurrences in very fat
subjects and the results were good in all, no relapses having occurred after
periods varying from 5-11 years, and one of the patients having been
delivered at term without inconvenience. Of the ventral hernias 3 were
spontaneous and 5 followed laparotomy, 2 of them being recurrences which
had been treated by other surgeons. The results were good in all cases after
7-12 years. T. W. P. L.

PiBONDiNi, E. Pielite larvata, cistalgica. [Pyelitis larvata cystalgica.]
Arch, ital di cJiir, 1920, 2, 502.

Patients with this aflection suffer from pollakuria, associated with
extremely painful micturition. The increased frequency of micturition is
both diurnal and nocturnal, and often presents great regularity ; the
stimulus occurring, for instance, every hour day and night. The disease is
very chronic, and neurasthenia results through prolonged suff^ering, disturb-
ance of rest, and hopelessness of recovery. The urine is somewhat turbid,
and from time to time there may be slight haematuria : pain in the region
of the kidney is absent. The clinical picture suggests an obstinate cystitis,
either tuberculous or insufficiently treated. Evidences of tubercle are
absent, and there is no wasting. Objectively, the most prominent symptom
is the extreme pain and desire to micturate produced by pressure on the
bladder, whether applied above the pubis or per vaginam. Palpation of
the renal regions may reveal a slight tenderness, but this is often entirely
absent.

The urine is always turbid, acid, and contains a small amount of
albumin and numerous pus cells. The daily quantity may be normal ;
there is often, however, a slight degree of polyuria. The amount of noc-
turnal urine is little less than or equal to the diurnal urine, and the normal
fluctuation that occurs during the day is less pronounced, the secretion
taking place more regularly, with, however, occasional sudden increases as
if from transitory retention. When these changes in the secretory process
are well marked, as shown in the accompanying figures, and the other
symptoms mentioned are present, the diagnosis of cystalgic pyelitis is
almost certainly established.

SURGERY

241

Urine Collected at Intervals of Tujo Hours.

Normal.

Pyelitis.

C.C.

c.c.

138

120

628

365

845

200

196

180

170

156

1275

Normal.

Pyelitis.

Sp. gr.

Sp. gr

1022

1013

Cystoscopy and catheterization of the ureters are difficult in tliese cases,
owing to diminution in the capacity of the bladder. In the cases in which
Pirondini succeeded in using these measures the bladder appeared normal
except for slight congestion of the ureteral orifices, and the ureters showed
the signs of pyelitis.

It appears probable that the disease may originate in two ways, either
as a primary haematogenous pyelitis or as an infection ascending from the
bladder, which has become subsequently cured so far as the vesical infection
is concerned. In either case the cystalgifi is to be explained as a reflex
symptom originating in the renal pelvis or ureter.

With regard to differential diagnosis it has to be remembered that in
cases of prolonged cystitis with slight or doul)tful pyelitis an obstinate
cystalgia is more likely to be dependent on a slight residual C3'stitis of the
neck of the bladder than on pyelitis larvata ; and that poUakuria with
cystalgia is in some instances purely functional in origin.

Satisfactory treatment is difficult, especially in long-standing cases.
Distension of the bladder should be carefully avoided, and in washing out
the bladder, which, however, is rarely indicated, the limit of tolerance should
not be reached and the double current should be employed with the channel
of afflux smaller than that of efflux. The treatment generally is similar to
that adopted in vesical tubercle ; sedatives are preferable to pure antiseptics,
and may be administered by the mouth and per rectum as well as directly
to the bladder itself. Attempts should be made to lessen the pyelitis, and
for this purpose the author has found instillations of collargol useful.
Intense painful and febrile reaction follows the instillation, but distinct
amelioration results, without, however, definite cure. T. W. P. L.

BoBELi.!, E. Ernie inguino-superficiali e diverticoli del sacco. [Superficial
inguinal hernia.] PolicUn., 1920, 27 (Sez. chir.), 341.

Superficial or subcutaneous inguinal hernia, two cases of which are
described by the author, is rare. The essential characteristic of the condi-
tion is the situation of the sac immediately beneath the superficial fascia,
and one of its more constant features is its association with incomplete
descent of the testis. The sac itself is frequently bilobed, one portion
following the usual course of the hernial protrusion beside the spermatic
cord, the other becoming superficial in front of the aponeurosis of the
external oblique muscle and being directed externally towards the iliac
spine, or upward in front of the sheath of tlie rectvis, or downward into
Scarpa's triangle, or inward and backward into the perineum. The former
part of the sac is always narrow, empty, partly obliterated, or subdivided

242 ABSTRACTS

by adhesions, and extends for a variable distance into the scrotum, at
times, especially when the testicle is not retained, reaching the bottom
of the scrotum. The subcutaneous part of the sac contains the displaced
viscera when hernia is present, and when empty is usually completely
pervious and in free communication with the central portion of the sac.
Although usually bilobed, the sac is sometimes single, a condition chiefly
met with in cases of acquired hernia. In such cases the sac, being of
secondary formation and meeting with some obstacle to its descent along the
cord, is deviated in toto : in congenital herniae, if the processus vaginalis
should offer any obstruction to the descent of the viscera, a lateral diver-
ticulum is formed. In the former case a simple sac, in the latter a bilobed
sac results. When superficial inguinal hernia is associated with retention
of the testicle, this organ is usually found in the subcutaneous portion of
the sac, either free or fixed by remains of the gubernaculum : at other times
it is retained in the inguinal canal or immediately outside the external ring,
and in this case, when the sac is bilobed, as in the author's two cases, the
testis is found near the bifurcation of the sac and in a position to obstruct
the passage of the herniated viscus into the scrotal portion.

Various theories have been adduced to explain the occurrence of the
lesion ; it is probable, however, that several factors are concerned, and vary
in different cases. With a simple sac bent on itself at the external ring, and
with the testis in its normal position, it will probably be found either that
the external ring is abnormally large, its columns lax, and the inguinal
canal directed more forward than normal, or that a badly-fitting truss has
allowed the viscera to pass the external ring w^hile preventing their descent
into the scrotum. When the sac is bilobed, the testis, usually situated at the
point of bifurcation, offers an impediment, and the descending viscus is
deflected accordingly ; or, when the testicle is in its normal situation,
obliteration or stenosis of the terminal portion of the sac will be found,
or some mechanical external cause, such as excessive pressure of a truss.
When the testicle is present in the superficial portion of the sac the hernia
is probably due to the testicle itself, which paves the way for the subsequent
descent of the bowel, and this is the more probable when the abnormal
position of the testis is due to an anomalous fixation of the gubernaculum,
a condition met with in some cases and indicated by a band of fibrous tissue,
containing smooth muscle and elastic fibres, retaining the testis in its new
position. Such cases are due primarily to a congenital deviation of the
processus vaginalis. T. W. P. L.

NEUROLOGY

Trotter, W. On certain clinically obscure malignant tumours of the
nasopharyngeal wall. Brit. Med. J., 1911, ii, 1057.

Jacod, M. Sur la propagation intracranienne des sarcomes de la trompe
d'Eustache : syndrome du carrefour petro-spheuoidal : paralysie des 2^, 3^, 4^, 5^
et 6e paires craniennes. [The intracranial extension of sarcomata of the
eustachian tube : syndrome of the petro-sphenoidal junction.] Bev. neurol,
1921, 38, 33.

In 1911 Trotter first drew attention to a syndrome of peculiar interest
to neurologists, arising from the spread of and the infiltration of sur-

NEUROLOGY 243

rounding tissues by endotheliomata arising in the lateral wall of the
nasopharynx. When these growths project into the nasopharyngeal
cavity they are readily observed and give rise to no neui'ological symptoms,
but when there is little or no external projection, diagnosis depends entirely
on the recognition of the symptoms of infiltration of the nasopharyngeal
wall. These are, in Trotter's experience, remarkably constant. The region
of the pharyngeal wall particularly affected is the orifice of the eustachian
tube and the prominent cusliion below it formed by the levator palati.
External to the cartilaginous tube and this muscle lies the inferior division
of the fifth nerve, and latei'al to this the internal pterygoid muscle. The
tumour, which is commonly an endothelioma, appears to originate in the
substance of the pharyngeal wall and early involves the eustachian tube,
causing deafness ; the levator palati, causing defective mobility of the soft
palate on the affected side ; and then the inferior maxillary nerve, causing
neuralgia in the ear, the side of the head, the jaw, and the tongue. Ulti-
mately involvement of the internal pterygoid muscle prevents proper
closure of the jaw.

Deafness is usually the initial symptom, it is of eustachian tube type
and may be relieved temporarily by inflation of the tube ; it may not be
noted unless examined for.

The nexiralgic pain is always strictly of fifth-nerve distribution. In
one of Trotter's cases upward extension of the growth into the spheno-
maxillary fossa had involved the second division of the fifth nerve. Objective
sensory change appears some weeks or months later than the pain, which is
very severe and may, in the absence of other detected signs, give rise to a
diagnosis of trigeminal neuralgia.

The palatal defect is due to direct involvement of the muscle, and is
most apparent when the palate is at rest, for while the muscle may still be
able to contract, its relaxation is imperfect or delayed. Oedema of the
palate is a later symptom. As late symptoms, enlargement of the cervical
glands and imperfect closure of the jaw are common.

Diagnosis depends upon the fact that only a lesion of the lateral
pharyngeal wall could give rise to this combination of symptoms : deafness
of eustachian type, neuralgia of inferior maxillary division distribution,
and defective mobility of the soft palate. Digital examination usually
confirms the diagnosis.

Owing to late diagnosis. Trotter has not been able to obtain by opera-
tion a longer period of freedom from remission of symptoms than fifteen
months.

In a recent paper, Jacod, who is assistant in the laryngological clinic
of Professor Lannois at Lyon, describes a symptom-complex produced by
growths in this region of the pharyngeal wall. In his cases the tumour
spread upward through the foramen lacerum into the cranial cavity and
produced deafness of eustachian tube type, fifth-nerve neuralgia, and
paralysis of the optic, oculomotor, trochlear, and abducens nerves.

There seems little doubt that Jacod is describing the same type of
growth as that recorded earlier by Trotter, though the paralyses in Jacod's
cases are more extensive and seem to indicate either a terminal stage of the
condition, or more pronounced upward extension into the skull. When
the growth spreads up beside the body of the sphenoid we should expect
the optic nerve and the nerves lying in the cavernous sinus to be affected,
while it is easy to see that the seventh and eighth nerves, lying below the

244 ABSTRACTS

tentorium would escape. Jacod's first published series were recorded in
1914, and since this time he has seen seven fresh cases, the symptomatology
of which he reviews in his present paper, F. M. R. W.

Baudoin, C. Suggestion and auto-suggestion. Trans, from the French by
E. and C. Paul. George Allen ^- Umvin, London, 1920.

Thoughout the period of the Freudian upheaval the Nancy school has
continued to work in its own special province of suggestion, and it has not
been disturbed in the pursuit of its own views by the revolutionary views
of Vienna. It has not denied their truth, rather it has congratulated the
Freudians that their findings coincide so well with its own ; but it has
not thought that the new methods arre of much value in practice, though of
undoubted theoretical interest. In this book Dr. Baudoin has described the
developments of the Nancy school, especially as they have been elaborated
by his friend and colleague Dr. fimile Coud.

' There is no hypnotism, only suggestion,' said Bernheim. ' There is no
suggestion, only auto-suggestion,' is the new dictum. ' Suggestion is the
subconscious realization of the idea.' The meaning of this sentence is the
theme of Dr. Baudoin's book. The realization of the idea is subconscious.
This implies that it has nothing to do with will ; indeed, the operation of
will is worse than useless if it comes into conflict with an opposing idea
charged with emotional tone. The will is always defeated by the idea.
When we are learning to ride a bicycle we see a stone in the road ; v/e try
to avoid it and we collide with it. What has happened 1 The idea that we
shall strike it has occurred, and this idea has been charged with the emotion
of fear. To this we have opposed our will and assuredly it has not helped
us. Now this is very curious. The road may have been twenty feet wide,
the stone an inch or two. To have hit it fortuitously was unlikely, but we
did hit it. The idea that we should do so was conscious, but the mechanism
by which the idea was realized was concealed, was subconscious ; and if
the hitting was not fortuitous it must be a very accurate and perfect
mechanism whicli produced such a result. The will not only failed to help
us, but, such is the teaching, the more it was called into play, the more
certain would we be to hit the stone. This phenomenon of the worse than
useless efiect of the will is called the law of reversed effort. ' So long as
the imagination is adv^erse, so long as a counter-suggestion is at work, effort
of the conscious will acts by contraries.' ' When the will and the imagina-
tion are at war, the imagination iiivariahly wins the day.'

The idea which sliould have filled the tyro's mind was that the road
was wide and the stone small, and that it would be really difficult for so
poor a rider to hit it. These thoughts would certainly have been true, and
tlie beginner was as free to consider them as those which he actually did
entertain. The importance of this in psychotherapy is obvious. The
insomnic lies awake because he is possessed with the idea that he will not
sleep, and this idea is charged with the fear of what will happen if he does
not. The more he tries to go to sleep, the wider awake does he become.
The man who cannot concentrate believes that for him it is impossible, and
all his conscious efforts result only in further wandering from his subject.
The task of the physician is to bring the attention of the patient to the
opposite idea, and to teach him how to hold it there. This is most easily
and most profitably done in times of bodily and mental relaxation ; for then

NEUROLOGY 245

the will is most in abeyance, and then contact with the subconscious is most
easily obtained. Tliat a method of this kind will cure a laro;e number of
the neuroses is certain. It has been well established that the expectation
of symptoms is a fruitful cause of symptoms, but the claim here is that not
only will this procedure cure those common manifestations which used to
be called neurasthenic, but that the graver obsessional and compulsive cases
are also restored to health by its employment. On this point it is difficult
to give an opinion, but the question should certainly be investigated.
Psycho-analysis is not regarded even by its devotees as a sure remedy for
these conditions ; and, if it were, something much shorter must be found if
more than a small ]5ercentage of neuropaths are to be relieved.

The Nancy school goes still farther, and says that success has followed
in certain cases of intractable organic disease, such as chronic eczema and
varicose ulcer. We know that the regulation of internal secretions and of
blood-supply is affected by the emotions, and it is therefore not impossible
that emotional thought can alter the course of organic disease. This is
a hard thought to many, but the subject should be approached with an
open mind. The line between functional and organic is vague ; who shall
say where the possibilities of psychotherapy must end ?

T. A. R.

Bbown, W. Psychology and psychotherapy. London. Edward Arnold,
1920.

In this book of about two hundred pages, Dr. Brown gives the impres-
sion of having attempted to cover too much ground ; and what he has written
lacks proportion and plan. It hardly seems necessary in a little book on
psychology and psychotherapy to enter the unknowable land of the relation
of mind to brain, and in some twenty pages the subject has been compressed
to the point of being unintelligible. Thus, ' If we explain consciousness in
terms of brain change we are also explaining intellectual processes, which
are a part of consciousness, in this way. That is to say, we are explaining
consciousness in terms of something which needs consciousness for its
explanation.' As the sentences stand, surely we are only explaining
intellectual processes in terms of brain change. It may be that Dr. Brown
regards it as an objection to the materialistic view that we need consciousness
to understand consciousness, but that objection must apply to any theory of
consciousness. Whatever may be the meaning of the sentences quoted, they
need much amplification to bring it out. In a later part of the argument,
it is curious to find the statement that the materialistic view wipes out the
possibility of survival after death. Psj^chology has nothing to do with such
a subject.

The clinical part of the work is occupied almost exclusively with war
eases, and though he was very successful in abolishing hysterical symptoms
taken in hand at an early stage, Dr. Brown seems to have been too easily
satisfied in his delayed cases with immediate results, and too readily satisfied
with odd explanations. He records a case, already described by him else-
where, which he must therefore deem important, where a young man had
loss of orientation so that when he was in a 'bus which turned through
a right angle, he felt as though it had continued in a straight line. By an
analytic investigation Dr. Brown arrived at a suppressed experience of
a tumble in childhood, when the patient had fallen laterally to the ground

246 ABSTRACTS

— that is, through a right angle. Shortly after this discovery the disorienta-
tion ceased ; and in a brief interval the patient passed finally from
observation. This case is described by Dr. Brown to illustrate therapy by
hypnotic recovery of lost memories ; and the more it is examined the less
does it seem to illustrate anything at all.

Is there any human being who has not, at various periods of infancy
and childhood, fallen through a right angle ? Is a cure which has been
observed for a few days only worth talking about ?

Certain remarks made about soldiers after heavy fighting are unfortu-
nate. Some of the men ' were keeping up with obvious effort rhythmical
tremors which had no doubt been involuntary and irrepressible some hours
before, but were now within the field of voluntary control. By distracting
these cases with a rapid sequence of questions as to the origin of their
disability, I was able to bring the tremors to an end.' The view is quite
clear ; because their tremors were brought to an end by distraction, they
were voluntary. This is the view of the sergeant-major ; it is also the view
of a certain type of unimaginative doctor ; it is an astounding view to come
from a reader in psychology. If I am sad and a friend comes in and
distracts me, does that imply that my sadness was voluntary and that
I could have stopped it myself ? Moreover, can rhythmic tremor be kept
up voluntarily for any length of time 1

On the whole, it must be said that the book is one of the many on
psychotherapeutic subjects which had better not have been written. At
the moment we are almost submerged beneath a flood of literature of this
kind, disorderly both in thought and expression, and of no value. It is
a pity that Dr. Brown has yielded to the impulse to add his quota to the
muddy torrent. To the practitioner dealing with civilian cases the book
wall give no help ; as a guide to modern psycho-pathology it is useless
because of its compression and obscurity ; as an epitome of general philosophy
it is absurd. It is diflicult to see for what class of reader it is intended.

T. A. R.

Andb^i-Thomas. Le reflexe pilomoteur. [The pilomotor reflex.] Bev.
neurol, 1920, 27, 1139.

Andre-Thomas describes the receptive field, appropriate stimuli, and the
characters of the response in this reflex under various conditions.

In the normal subject the pilomotor muscles may be excited directly
by mechanical stimuli or reflexly. As a reflex it may be obtained by
various stimuli applied to the skin, such as cold, friction, and the electric
current. To unilateral stimuli the response is unilateral and may spread
to the whole of the stimulated half of the body, or it may be restricted to
one or more segmental areas. Certain cutaneous areas are particularly
receptive, the nape of the neck and shoulders and the lower part of the
axilla. When elicited from the neck the response is descending, and
stronger stimuli are necessary to produce it over the head and neck. On
the limbs, the extensor surfaces give the response more readily than the
flexor surfaces. Bilateral stimuli produce a bilateral response.

In lesions of the spinal cord the response is exaggerated immediately
below the upper level of the lesion. In total divisions of the cord, there
are two forms of response : one above the level of the section, the ' reflexe
encephalique ', and one below, the ' reflexe spinale '.

NEUROLOGY 247

The spinal reflex in total divisions of the cord makes its appearance
when the isolated portion of the cord emerges from spinal shock — that is,
simultaneously with the mass retlex. It is elicited by the same stimuli as
this reflex, namely, passive movements of the legs, &c. In these circum-
stances, the factors governing the distribution of the spinal reflex are the
same as those governing that of the reflex sweating described by Head and
Riddoch — that is, the distribution of the thoracico-lumbar white rami.

In partial lesions and in various diseases of the spinal cord, the response
varies and is often diflioult of interpretation. It is normal in poliomyelitis.
In syringomyelia, variations in the response follow the distribution of
vasomotor" and trophic disturbances. In peripheral nerve lesions, the reflex
response is abolished over the area of sensory changes, but, as Trotter and
Davies showed, a local response to stimulation persists.

The cerebral reflex, that is, the response above the level of a cord
lesion, varies greatly in facility and distribution. It descends to the level
of the sympathetic distribution of the isolated portion of the cord.

In the normal subject the reflex is elicited by peripheral stimuli and
also by various emotional states. The quality of the stimulus in both cases
is similar and is strongly affective. In the former case, the sensations
aroused by stimulation are of the aft'ective variety and are unpleasant.
Hence when the skin is anaesthetic no response can be obtained from it.
The emotions producing the reflex are also unpleasant in quality. Fright
and horror are the most adequate stimuli, but any profound emotion, what-
ever its quality, may be sufficient to produce it. The reflex of emotional
origin is bilateral, that due to peripheral stimulation may be unilateral.
The pilomotor refle.K may therefore be regarded as an aflective reflex.

F. M. R. W.

BiOussY, G. Les lesions du corps thyroide dans la maladie de Basedow. [The
thyroid lesions in Graves's disease.] Bev. neuroL, 1920, 27, 918.

Roussy distinguishes the following forms of Graves's disease : the
common or essential form ; secondary forms associated with infections of
the thyroid (granulomatous or non-specific), with maHgnant disease, or with
goitre in regions where goitre is common ; and abortive forms of varying
nature.

The essential lesions of the disease are found in the thyroid, thymus,
and lymphatic glands. According to Roussy, the changes in the thyroid
are characteristic and allow of diagnosis from microscopic examination alone.
The features of the thyroid lesion are a parenchymatous hyperplasia
aSecting acini, epithelium, and colloid substance. The acini are smaller and
more numerous than normal. Their form is irregular and the lumen may
be absent. The cells are cubical and form intra-alveolar projections. Mitotic
figures are rare, but desquamation is common. The colloid substance is
diminished in amount, more fluid than normal, and stains feebly. Additional
changes noted by Roussy and Clunet are clumps of eosinophil cells and of
lymphocytes. The eosinophil clumps are found in about 50 per cent, of
cases and are peculiar to this disease. The hyperplasia, though not
characteristic in appearance, is so in its universal distribution throughout
the aflected gland.

A persistent or hypertrophied thymus is found in about 60 per cent, of

248 ABSTRACTS

cases, and proportional to this there may be enlargement of the lymphatic
glands of neck, thorax, and abdomen.

The characteristic blood-changes consist in a leucopenia with a relative
lymphocytosis, and a delayed coagulation time.

There are no constant lesions found elsewhere in viscera, glands, or
nervous system. The sympathetic ganglia and trunks may show fatty
infiltration and their cells degenerative and atrophic changes, but these
changes are not constant or essential.

In long-standing cases various minor degrees of change may be found
in various organs, but these are not constant and may be agonal changes.

The pathogenesis of the disease. While admitting that the sym-
pathetic system probably plays a part in the symptomatology of the disease,
Roussy thinks that this is not essential and is confined to the carriage of
nervous impulses set up by toxic factors.

The various pluriglandular theories he dismisses as ingenious hypo-
theses without foundation. For him disordered thyroid function is the
essential basis of the disease. He considers that dysthyroidism rather than
hyperthyroidism is concerned. This would explain the association of
symptoms of myxoedema and of Graves's disease in a single patient, and the
fact tliat extract from the thyroid in Graves's disease may be less active than
that from a normal gland. The relation of the thymus to the thyroid
lesion remains obscure. In conclusion, Roussy would sum up as follows :
that Graves's disease probably arises from an unnoticed inflammatory lesion
of the thyroid and perhaps of the thymus also, which is followed by thyroid
' dyshyperplasia ' and the production of an excessive and perverted secretion,
which has a selective toxic action on certain organs or parts of the nervous
system.

Of methods of treatment, Roussy considers radiotlierapy the most
efficacious, while the estimation of the basal metabolism is an important
method of estimating the degree of thyroid activity and of controlling
treatment.

From his own extensive observations during the war, Roussy does not
believe that Graves's disease follows emotional disturbance or shock.

This abstract is taken from a report of a paper by Roussy read at the
24th annual congress of alienists and neurologists of French-speaking
countries, held at Strasbourg during August 1920. At the end of the paper,
the discussion which followed it is very briefly reported.

F. M. R. W.

WestfhaIi, a. Uber seltene motorische Erscheinungen bei multipler Sklerose,
nebst Bemerkungen zur Differentialdiagnose gegeniiber der Encephalitis epide-
mica. [Unusual motor symptoms in disseminated sclerosis, with reference
to the differential diagnosis from epidemic encephalitis.] Deutsche Ztschr.
f. NervenheUTi., 1921, 68-9, 128.

Westphal records three cases of disseminated sclerosis, two of which
were confirmed by autopsy, in which unusual motor symptoms occurred
suggesting the presence of encephalitis.

(1) A man of 35, who came under observation with widespread
choreiform movements of limbs, grimacing movements of the face, and
general restlessness. Speech was unintelligible, and standing and walking
were impossible on account of the persistent involuntary movements. The

NEUROLOGY 249

tendon-jerks were increased, the abdominal reflexes alisent, and tlie plantar
responses both extensor. It was not possible to determine the condition of
the fundus oculi, nor the presence of nystagmus. The involuntary move-
ment persisted during rest, but was grossly aggravated during movement,
so that co-ordinated movement was impossible. During the six weeks
before the patient died, the general unrest steadily increased. Speech
remained practically unintelligible. The patient's mental state appeared
normal, and he was perfectly oriented. It appeared that he had been ailing
for three years. The picture was one of severe chorea with signs of
pyramidal tract lesion. Examination of the brain revealed the characteristic
lesions of disseminated sclerosis in great number involving all parts of the
brain. Many of the foci were {[uite recent and their association with the
blood-vessels was noteworthy.

(2) An unmarried woman of 23. For some years the menses had
become irregular and she had lost practically all her hair, becoming bald.
Her present illness dated back two years and had begun with involuntary
movements in the legs following an air raid over Cologne in 1917. Soon
walking became impossible and a tremor appeared in the left arm, and in
head and trunk. Her mental state gradually deteriorated, but her hair
had returned during these two years and she had become enormously fat.
On examination, there were seen clonic flexion-extension movements of
both lower limbs and in the left arm. She was unable to sit up, stand, or
walk. The musculature of the rvAit arm and of the face were alone
unaffected. There was no paralysis. Both knee- and ankle-jerks were
absent, the abdominal reflexes were absent, and the right plantar reflex was
extensor. The left was unobtainable. There was nystagmus and she was
incontinent of urine. Mentally, she was euphoric and fatuous. The clonic
movements of the limbs increased under the influence of emotion. The
pupil reactions varied from time to time from a good light reaction to
complete immobility.

While under observation her speech became slow, and temporal pallor
of the optic disks developed. Finally, contracture of the legs developed, she
became emaciated, and died.

Autopsy revealed the presence of numerous focal lesions in the nervous
system, of hydrocephalus, and of atrophy of the optic thalami. Micro-
scopically, typical lesions of disseminated sclerosis were found, most
abundant in the basal ganglia, cerebellar cortex, dentate nuclei, and posterior
columns of the cord. Many of them were recent.

The clinical picture was one of dystrophia adiposo-genitalis with myo-
clonic symptoms and pyramidal signs.

(3) A man of 29, with a very recent history of contractions in the left
leg. Examination revealed tonic spasms of the flexors and dorsiflexors of
the leg and toes. These spasms were of varying duration and came on at
frequent intervals, afl'ecting different muscles in different attacks. The
patient walked with the affected leg partly flexed and with foot and hallux
strongly dorsiflexed. Occasionally the spasm was purely clonic. The
plantar response on this side was extensor in type. The abdominal reflexes
were present on both sides, the pupil reactions normal, and there was no
squint, though there was a history of transient diplopia. There was
abnormal pallor of the disks, but no defect of vision. The Wassermann
reaction in the blood was neofative. The illness becjan in 1919, and durinj::
1920 the spasm described disappeared finally, to give place to fresh motor

250 ABSTRACTS

symptoms. Athetotic movements appeared in the left arm. These
developed from a slow mobile spasm to a wild jactitation of the limb
accompanied by severe pain locally in the course of a few months. He was
given a series of doses of silver-sal varsan totalling 5-0 grm. and improved
considerably. His present condition is that there are no signs of pyramidal
tract lesion, no sphincter disturbance, no sensory changes. The optic disks
remain unchanged, and there is some nystagmus. Some movement of the
left arm persists.

These three cases were all observed during the course of an outbreak
of epidemic encephalitis. F. M. R. W.

NoNWE, M. Zur Klinik der Myelomerkrankung der Wirbelsaule. [Myeloma
of the spine.] Neurol Centralbl, 1921, 40, 2.

Nonne gives a short review of the principal observations on this con-
dition and a summary of the clinical picture. He describes a case in which
a myelomatous nodule in the first thoracic vertebra gave rise to peculiar
nervous symptoms. The patient was a man of 57, who came under observa-
tion for pains in the neck and arms, and for progressive wasting and pallor.
A first examination revealed nothing but tenderness of the lower cervical
and upper thoracic spine, albuminuria, and anaemia. He was admitted to
hospital and four days later developed retention of urine. At this time there
was marked tenderness of the lower cervical spine, a slight angular curve, and
wasting of the ulnar muscles of the right arm and general weakness of this
limb. Priapism and cyanosis of the penis appeared, myosis and loss of light
reaction in the pupils, and then generalized cyanosis of the face, lip, and
extremities. The cerebrospinal fluid was practically normal, and X-ray
examination revealed rai'efaction of the first thoracic vertebra. He died
six days after admission to hospital. The diagnosis made during life was
meningo-myelitis of the cervical cord of unknown origin.

At autopsy, the first thoracic vertebra was practically completely
replaced by myeloma, which, however, did not project into the spinal canal.
There were multiple myelomata in spine, ribs, and sternum. To the naked
eye and microscopically the spinal cord and meninges were normal. The
priapism remained after death.

Myosis and priapism are known to occur in lesions of the first dorsal
and lower cervical segments of the cord. Nonne recalls observations in
which so-called toxic nervous symptoms have been described in the nervous
system as occurring in the course of cases of malignant disease in various
parts of the body (Oppenheim, Bruns, &c.), and he concludes that the nervous
symptoms in his case are of this nature. Although myeloma may not be
malignant in the same sense as carcinoma, yet its course is invariably fatal,
and he suggests that the appearance of nervous spnptoms related to neigh-
bouring segments of the cord in association with myeloma of the first dorsal
vertebra may be regarded as evidence of malignancy in myeloma.

NEUROLOGY 251

Lsciiin:, P., et Lkebmitte, J. Une observation anatomo-clinique d'un cas
de ramollissement cerebral consecutif a I'obliteration del'artei'e sylvienne gauche
par une embolie metallique. [Cerebral softening from a metallic embolus in
the left middle cerebral artery. J llev. ncurol., 1920, 27, lllG.

The patient, a healthy soldier of 30 years, received multiple small shell
wounds on August 31, 1918. Included among these was a small punctured
wound below and behind the left angle of the jaw.

When observed on the same day the patient's grave condition was in
striking contrast to the trivial nature of his external injuries. He was
semi-conscious and had a rapid feeble pulse of 140 per minute. He answered
questions by an inarticulate grunt, and the most that could be elicited from
him was the repeated phrase ' fait mal '. There was no true paralysis, but
slight rigidity of the right arm was noted.

On the following day he was unable to utter a word, there was
complete aphasia. He appeared to comprehend what was said to him
perfectly. The slight rigidity of the right arm noted earlier persisted, but
did not interfere with voluntary movement of the limb. There were no
local signs of a wound of the carotid artery.

On the third day (September 3) there was a complete right hemiplegia,
with flaccidity of the paralysed limbs and loss of tendon-jerks on the right
side. The right plantar response was of Babinski type. Complete aphasia
remained.

On the three following days the patient's general condition grew
steadily worse. He was somewhat delirious, the right hemiplegia persisted,
the patient was speechless, but could close both eyes to order. He died on
September 6.

Examination ijost mortem revealed lobar pneumonia of the right lung
and a small punctured wound of the internal carotid on the left side just
above its point of origin from the common carotid artery. The artery was
normal elsewhere. The anterior cerebral artery and the circle of Willis
were normal. On opening the left Sylvian fossa, a black speck became
visible on the middle cerebral artery three centimetres from its junction
with the circle of Willis. The artery was found to be completely occluded
here by a small shell fragment. Distal to this, the artery and its branches
were thrombosed. The other vessels were normal.

On horizontal section, the left centrum semi-ovale in its middle segment
was softened and diffluent, livid in colour, with several haemorrhagic areas.
The external part of the head of the caudate nucleus and the two external
segments of the lenticular nucleus were also softened and bluish in colour.
The external medullary lamina and the external capsule were not recogniz-
able, being replaced by a cavity. The insula and all the cerebral convolutions
were normal. The thalamus appeared normal.

Microscopically, the frontal convolutions were normal both as regards
blood-vessels and cells. The Rolandic convolutions showed no vascular
lesion, but the cells of Betz were in a state of chromatolysis. There was
some oedema of the cortex of the insula and some diapedesis round the
vessels. In short, the cortex was relatively little altered. The thalamus was
also virtually intact, and, beyond excess of lipoid granules in the cells, was
normal.

The caudate nucleus was altered throughout its whole extent. Numerous
veins were thrombosed, there was haemorrhage from the capillaries, and the
nerve-cells were grossly degenerated. The putamen was completely necrosed

252 ABSTRACTS

and its vessels thrombosed. In the external segment of the grlobus pallidus
there were numerous capillary haemorrhages and oedema. The nerve-cells
were relativelj^ intact.

In the internal capsule the fibres were separated by oedema, but were
otherwise normal. Numerous compound granular corpuscles were seen here.

In their commentary on the case, Lecdne and Lhermitte note the initial
absence of localizing symptoms, then the appearance of complete aphasia
without signs of hemiplegia except for the trivial change in tone in the
muscles of the right arm for twenty-four hours. Not less striking was the
absence of definite evidence of a wound of the internal carotid artery in
the neck. 1 he severity of the general cerebral symptoms, the rapid develop-
ment of aphasia, hemiplegia, and death from a small metallic embolus, the
entry of which was missed during life, suggest that some at least of the
fatal cases said to be due to shell explosion without wound may have
a similar origin.

According to the authors, it is in connexion with the question of the
cerebral arterial supply that the case has its greatest interest. Contrary to
what some observers have stated, the cerebral cortex obtains its blood-supply
from a network in the pia formed by branches of all three cerebral arteries.
So free is the anastomosis between the branches arising from the three
parent arteries, that obliteration of one of these scarcely affects the blood-
How through the network. If, as in a young subject, the vessels are healthy,
obliteration of one of them does not lead to an appreciable lesion of the
cortex. This is well seen in the case here recorded. The basal arteries, on
the other hand, are strictly terminal. They arise from all three cerebral
arteries and from the anterior choroid and communicating arteries. Block-
ing of a single set, such as those arising from the middle cerebral artery,
should give rise to a well-defined area of softening.

After shortly reviewing the various statements as to the blood-supply
of the basal ganglia (Beevor, Heubner, Charpy), the authors point out that
in their case, from blocking of the basal vessels arising from the middle
cerebral artery, there resulted softening and complete necrosis of the
putamen, external segment of globus pallidus, and of head and middle part
of caudate nucleus. The internal capsule was merely oedematous and
contained numerous granular corpuscles, and the thalamus was intact. In
short, the middle segment of the centrum semi-ovale was necrosed, and on
this lesion the hemiplegia depended. F. M. R. W.

DiDE et GuxBAUD. Precede electif de coloration des granulations lipoides
cellulaires dans les centres nerveux. [Special staining method for lipoid
granules in nerve-cells.] Bev. neurol, 1920, 27, 1124.

The method is applicable to alcohol or formalin fixed tissue in pal-affin
sections.

(1) Stain for a minute in a freshly prepared solution of methyl- violet
grms. 0-5 in 100 c.c. of anilin water.

(2) Then fix for a minute in a solution of iodine grms. 5-0, potassium
iodide gms. 5-0 in 150 c.c. of distilled water.

(3) Decolorize in 90 per cent, alcohol, and then in acetone until no more
blue or iodine comes away from the section.

(4) Wash in distilled water.

(5) Counterstain in 0*5 per cent, eosin solution.

(6) Dehydrate and mount in neutral balsam.

NEUROLOGY 253

Myelinated fibres stain pale violet; nerve-cells rose with pale violet
nucleus and blue- violet nucleolus ; lipoid granules in cells and in vessel-
walls and neuroirlia nuclei stain an intense blue.

The colouring is said to be permanent. F. M. R. W.

Habbitz, F. ' Encephalitis ' neonatorum. Norsk. Mag. f. Lccgevklensh,
1921, 82, 25-30.

Harbitz describes as a pathological cui-iosity a case of a child which
survived birth only by about 14 hours. It was in about the thirtieth week,
and the mother, who was a married woman with one child, suffering from
albuminuria and pyuria. The infant showed no sign of syphilis, but the
liver was cirrhotic, the kidneys showed doubtful signs of nephritis, and
there were haemorrhages in the skin, kidneys, and peritoneum, as well as
a considerable haemorrhage of the meninges, originating in all probability
from an aneurysm of an artery in the Sylvian fossa. In addition to jaundice
and ascites, internal hydrocephalus was found; and scattered throughout
the central ganglia and the cortex of the cerebrum were large, greyish-white
and yellow necrotic patches which were partially calcified. Small granules
of fat were grouped round the blood-vessels of the brain. Harbitz, who is
professor of morbid anatomy in Christiania, confesses to ignorance of the
aetiology of this condition. The internal hydrocephalus was evidently
secondary to this condition, which is undoubtedly more common among the
new-born than is generally supposed, and which Harbitz gives the com-
paratively non-committal label ' encephalitis '. C. L.

LiNDBEBG, G. Om posttraumatisk seros meningit hos barn. [Post-trau-
matic serous meningitis in children.] Hygcia, 1921, 83, 15-24.

Lindberg suspects that serous meningitis is a comparatively common
condition in children as a sequel to injuries to the head. Yet the published
accounts of such cases are scanty — a fact traceable to the infrequency with
which lumbar puncture is undertaken. Lindberg records two cases. One
was that of a boy, aged 10, who fell on the back of his head as he was
playing. The slight abrasion was ignored, but a couple of days later he
developed headache and general hyperaesthesia. Later he became drowsy
and very sensitiv^e to sound. The headache became more severe, but he did
not vomit. On examination he presented the characteristic signs of severe
meningitis, and the case would have been dismissed as one of tuberculous
meningitis but for the history of a fall. Lumbar puncture revealed a pressure
of 200 mm. and yielded 15 c.cm. of perfectly clear fluid, in the sediment of
which were only a few lymphocjH^es. Nonne's and Boveri's potassium per-
manganate reactions were negative. When lumbar puncture was repeated
some time later, the pressure had fallen to 180 mm. Improvement rapidly
followed, and though the boy was forgetful for some time, he ultimately
recovered completely. In the second case the cerebrospinal fluid was under
as high a pressure as 300 mm. The withdrawal of 20 c.cm. effected an even
more dramatic improvement than in the first case. This patient also
recovered completely, and Lindberg is inclined to attribute both recoveries
to the relief of pressure effected by lumbar puncture. It is impossible to
say v/hat the prognosis is in such cases in the absence of lumbar puncture,

IV. T

254 ABSTRACTS

for by this alone can the correct diagnosis be made. Lindberg's paper is, in
short, a plea for lumbar puncture in every case with signs of meningitis.

O. Li.

IiiiTDSTEDT, F. Contribution to the pathogenesis of sciatica. Acta Med.
Scand., 1921, 53, 733-7.

Lindstedt has examined a series of cases of sciatica, diagnosed as such
by others than himself in the principal hospitals in Stockholm. Among 100
consecutive cases he found as many as 91 wliich presented static changes of
various kinds. Serious diseases of the knee were found in 14 cases, a history
of rheumatic arthritis in 12, hip disease in 11, varicose veins in 8, affections
of the spine, such as spondylitis deformans, fracture. &c., in 8, and pronounced
flat-foot in another 8. In 5 cases there were pronounced traumatic injuries
to the foot, and in 4 a high degree of relaxation of the ligaments of the
knee associated with genu recurvatum. In as many as 7 cases the complica-
tions of sciatica were of gonorrhoeal origin. Lindstedt supplements these
facts with the following comments : The diagnosis of sciatica having been
made by various. hospital physicians, not by himself, the objection could not
be raised that his cases were in any sense picked. Most of the complications
detected were serious and conspicuous ; their coexistence with the sciatica
could not be merely accidental, for the occurrence of affections of the knees,
of polyarthritis, varicose veins, and flat-foot was too frequent to be explained
away thus. Indeed, some of these complications were of a relatively rare
kind. Again, when they were unilateral, they were invariably on the same
side as the sciatica. Lindstedt concludes that sciatica is often an irradiating,
reflected neuralgia, analogous to the trigeminal neuralgia following pres-
byopia or toothache. C. L.

Schmidt, V. 100 Tilfaelde af Kecurrensparese. [100 cases of paralysis of
the recurrent laryngeal nerve.] Uosp.-Tid., 1921, 64, 17-21.

Schmidt has examined the records of 85 cases of paralysis of the
recurrent laryngeal nerve treated at the Rigshospital in Copenhagen, and
of 15 similar cases at another hospital. He tabulates these cases so as to
show the comparative frequency of the different causes, the sex incidence
and the comparative number of right- and left-sided cases. As for the age
incidence, when the bulbar, post-infectious, and traumatic cases under the
age of 3 years were excluded, it was found that there was a steady rise
from 35 to 60. After this age there was an equally steady decline. In
about 60 cases the cause of the paral